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Health Information: What Can Mobile Phone Assessments Add?

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Margareta Warrén Stomberg at University of Gothenburg
Margareta Warrén Stomberg
Birgitta Platon at Region Västra Götaland
Birgitta Platon
Annette Widén
Annette Widén
Annette Widén
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Ingegerd Wallner
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Abstract and Figures

In healthcare, pain assessment is a key factor in effectively treating postoperative pain and reducing the risk of developing chronic pain. The overall aim of this study was to investigate whether a mobile phone support system can be used as a basis to continuously document patients' health information in real time and provide conditions for optimal, individual pain management after cholecystectomy and hysterectomy procedures.In this pilot study, two randomly selected groups of patients provided information about their pain for one week postoperatively. One group responded via cell phones, and the other, a control group, responded using paper-based questionnaires.The mobile phone system was found to provide a fast and safe basis for reporting pain postoperatively in real time. The results indicate that on days 3 and 4 the mobile phone group reported significantly higher levels of pain than the control group, and the cholecystectomy patients reported significantly more pain at movement on days 3 and 4 than the hysterectomy patients.The mobile phone approach is an adaptation to modern technology and the mobility of individuals. This technology is user friendly and requires minimal support. However, as the sample size was small (n = 37), further studies are needed before additional conclusions can be drawn.
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Health Information: What Can Mobile Phone Assessments Add?
Health Information: What Can Mobile
Phone Assessments Add?
by Margareta Warrén Stomberg, RNA, PhD; Birgitta Platon, RNA; Annette Widén, RN;
Ingegerd Wallner, RN; and Ove Karlsson, MD
Abstract
In healthcare, pain assessment is a key factor in effectively treating postoperative pain and reducing
the risk of developing chronic pain. The overall aim of this study was to investigate whether a mobile
phone support system can be used as a basis to continuously document patients’ health information in real
time and provide conditions for optimal, individual pain management after cholecystectomy and
hysterectomy procedures.
In this pilot study, two randomly selected groups of patients provided information about their pain for
one week postoperatively. One group responded via cell phones, and the other, a control group, responded
using paper-based questionnaires.
The mobile phone system was found to provide a fast and safe basis for reporting pain
postoperatively in real time. The results indicate that on days 3 and 4 the mobile phone group reported
significantly higher levels of pain than the control group, and the cholecystectomy patients reported
significantly more pain at movement on days 3 and 4 than the hysterectomy patients.
The mobile phone approach is an adaptation to modern technology and the mobility of individuals.
This technology is user friendly and requires minimal support. However, as the sample size was small (n
= 37), further studies are needed before additional conclusions can be drawn.
Keywords: mobile technology; pain management
Introduction
Today, the amount of surgery being performed on a day-surgery (outpatient) basis or using the
enhanced recovery after surgery (ERAS) protocol is continuously increasing, which requires a well-
established routine to follow up on pain and other symptoms postoperatively.1
Pain assessment is a key factor in successful pain management, and numerous studies show the
necessity of treating postoperative pain effectively to reduce the risk of patients’ later developing chronic
pain.2–6 Consequently, a prerequisite for optimal pain treatment is continuous pain assessment, also after
discharge. Information that patients themselves provide is important in clinical research; however,
collecting patient-reported survey data is a challenge.
One method of data collection available for almost all Swedes is mobile phones. Similarly, much of
the worldwide population is also able to send and receive information this way. Thus, a flexible way of
obtaining health information is through its documentation via patients’ own mobile phones. In this
method, data from the mobile phone are directly transferred to a database available at the hospital, which
gives the patient more freedom because a measured value can be entered whenever the patient chooses or
2 Perspectives in Health Information Management, Fall 2012
it is requested. The method also enables professionals to adjust pain treatment immediately after receiving
data from the patient, thus also giving staff a more individualized concept of how the pain develops
throughout the day. This technique was tested in a pilot study, after which a more interactive and
comprehensive study of this technology will be implemented in our postoperative recovery process.
Objectives
The primary aim of this study was to investigate whether a mobile phone support system can, in real
time, provide a basis for obtaining continuous health information and provide conditions for optimal,
individual pain management. The secondary aim was to evaluate a mobile computer system for capturing
data (Medipal, Novatelligence AB, Stockholm, Sweden).
Methods
At random, an intervention group (using mobile phones to evaluate pain) and a control group
(responding by questionnaires) were created. The questions regarding pain evaluation were the same for
both groups and used a graded, numerical scale from 0 to 100. This pilot study was carried out from the
spring of 2010 until January 2011 at a university hospital in Sweden.
Participants
Adult patients who understood the Swedish language in speech and writing and could manage their
own mobile phones were invited to participate. Patients whose journal entries indicated alcohol and/or
drug abuse or memory impairment were excluded. Forty relatively healthy patients ranging in age from 18
to 66 years were allocated from the surgical waiting list. Of these, 20 patients had been admitted for a
planned vaginal hysterectomy and 20 for a laparoscopic cholecystectomy. After informed consent, during
the preoperative stage, these patients were randomized to either the mobile phone group or the control
group (Table 1 and Figure 1).
Mobile Phone Group
The patients in the mobile phone group were informed and thoroughly trained, preoperatively as well
as prior to their discharge from the hospital, to document their pain levels on the mobile phone every four
hours (from 8 a.m. to 8 p.m.). Furthermore, the participants in the mobile phone group and the charge
nurses had access to technical support and written instructions during the study period. Additional
assessments could be initiated by the patients at any time of the day.
Control Group
While these participants were given the same information regarding the pain evaluation questions as
the mobile phone group, they were required to answer them on paper-based questionnaires every four
hours for a period of four days after surgery. Additional pain assessments could be made on the
questionnaires by the patients at any time of the day.
Procedure
The study began in the hospital the day of surgery. Prior to the study period, the software program
was installed in the patients’ own mobile phones.
Each patient was given information individually and had the opportunity to test the application and
provide test answers. The functionalities of the mobile phone, including how to move from question to
question both forward and backward, as well as how to input a response and use the navigation keys, were
carefully explained.
The follow-up of the mobile phone group was conducted by using a numeric rating scale from 0 to
100 (0 = no pain, 100 = terrible pain) with a mobile computer system, Medipal (Novatelligence AB,
Stockholm, Sweden). After waking from the anesthesia, the patients’ mobile phones initiated pain
Health Information: What Can Mobile Phone Assessments Add?
measurements by a “push” function every four hours, for a period of six days following surgery. If the
patient did not respond, a reminder in the form of an incoming Short Message Service (SMS) was sent
once, after 13 minutes. The specified response time was a feature built into the program itself. Each
question appeared separately in real time on the mobile phone screen and disappeared from the screen
immediately after the response was given.
Communication was transferred between the handset and the company´s server via the mobile
network GPRS, General Packet Radio Service. From the server, the encrypted health information was
available to dedicated staff members in hospital.
The strong encryption used by this technology ensured the safe transfer of information through the
system. All patient-related information that was sent from the mobile phone, whether iPhone, Android or
Java was encrypted. In addition, only authorized users had access to patient information, and user names
and passwords were required for access. If an incorrect password was entered three times, the service was
blocked and could only be activated manually by an authorized technician at Novatelligence. All traffic
between the web browser and website was encrypted with a certificate. Medipal’s servers and databases
are hosted at www.interoute.com, which is not only ISO27001 certified but also holds data and records
for some Swedish public healthcare providers. Furthermore, Medipal’s server has the same security and
requirements as those prescribed for all medical record administration within Swedish public healthcare.
Patients were also able to report additional assessments between the specified time periods if they
experienced especially painful episodes. All health information was incorporated into the patients’ health
record. After six days, the nurse called the patient to remove the program from the mobile phone. At the
same time, designated nurses asked structured questions that focused on potential difficulties in managing
the mobile phone technology or in providing the daily responses to the questionnaires.
The control group received the follow-up questionnaire before surgery and was asked to reply to the
questions at the same points in time as the mobile phone group, starting immediately after waking from
the anesthesia. These questionnaires were returned in a prepaid envelope after the study period. No
reminders were given to this group, which was followed up for four days postoperatively.
Analysis
The measured values for pain were compiled for the different time periods in each day. These values
were subsequently analyzed for the two surgical procedures and the intervention and control groups. The
mean level of measurements was calculated for each day. It was a requirement that a measurement could
only be analyzed if the same participant responded correctly at all of the specified times of the days. If the
response was incorrectly made, the value measured was not analyzed. All the additional measurements
reported between the specified times, from both groups, were analyzed separately.
Mantel’s test was used to compare pain intensity between the surgical procedures and between the
intervention and control groups. The amount of contact between the in-hospital care unit and the
participants was documented, as was the patients’ need for technical support from Medipal.
Ethical Considerations
The clinic manager approved this pilot study, and after informed consent the patients were instructed
on the technology. Their identity was encoded with a fictitious identifier when the data were transferred.
In addition, the Medipal company ensured that no unauthorized person could access the data transfer.
Results
A total of 40 patients were allocated to the two groups; 20 used the mobile phone technology and 20
(the control group) answered the paper-based questionnaire. In all, 37 patients completed the survey. The
response period began as soon as the patients were awake after surgery and continued for a period of six
days for the mobile phone group and four days for the control group. The day of surgery was regarded as
day 1 (see Table 1).
4 Perspectives in Health Information Management, Fall 2012
The response rate on the day of surgery (day 1) varied, resulting in 35 responses from the mobile
phone group and 41 responses from the control group. No patient in the control group provided the
responses completely for all of the specified times. When surgery was performed late in the afternoon,
more responses were missed on that day. On days 2–4 postoperatively, the response rate was 100 percent,
and no internal data were missing for either group. On days 5–6 the response rate was 69 percent for the
mobile phone group; the control group was not required to answer the questionnaire on those days (see
Figure 2).
As Figure 2 illustrates, no patient fully completed all the answers in the control group (paper-based
questionnaires) on day 1, while one patient did so in the mobile phone group.
The cholecystectomy patients reported significantly more pain at movement on days 3–4 than the
hysterectomy patients (p < .001). On days 3–4 the mobile phone group reported significantly higher pain
levels.
Overall, additional pain assessments were made on 28 occasions in the mobile phone group, and none
were made in the control group. These assessments showed that the average pain at rest was 65 (range
40–100) for all the participants, regardless of diagnosis, additional responses, and response method, and
the average pain level at rest was about 40 (range 0–100) on days 1–4. Altogether, the pain level tended to
be highest in the afternoon and evening.
Telephone Follow-up
After the sixth postoperative day, the patients were called to remove the program from their mobile
phones and at the same time to evaluate the technology. When patients were asked to rank the difficulties
in handling the mobile technology, from 1 to 10 (1 = no problem and 10 = very problematic), the mean
value was 1.31, which indicates that the technology was not difficult to handle. Three patients requested
technical support for a total of four times during the study period.
According to the patients, the technology was not time-consuming, and they were all willing to use
the method again. Several of them, regardless of age, clearly expressed their preference for the mobile
phone technology compared to answering the questionnaire.
The participants who responded using the paper questionnaires did not report any problems with the
technique, although a few commented on the difficulty of remembering to make their reports at specific
points of time. No one in the control group made any additional assessments.
Discussion
This study focused on methods for obtaining health information from patients after surgery. The
results indicate big differences between the number of pain measurement levels received from patients
using the mobile phone system and from those using the paper questionnaires. In addition, the assessed
levels of pain were significantly higher from patients using the mobile phone method. There is hardly any
reason to suppose that the mobile phone group experienced a higher level of pain, as both surgical
procedures require pain medication, and both were included in the same number. An explanation for the
difference, similar to reasons suggested by Dupont et al.,7 could be that an electronic system may provide
an anonymous environment that is perceived as safer than paper questionnaires, thus eliciting more
credible answers. This method can be considered especially valuable since private and sensitive questions
had to be answered. Patients may thus have a higher level of confidence in the privacy of the method,
which encourages responses.
This study also showed that no participant from the control group completed all the requested
responses on the day of surgery (day 1), while one participant in the mobile phone group did respond at
all of the specified times. Such a lack of response would be understandable if all the participants in the
control group had undergone surgery later in the day and were therefore not strong enough to answer the
paper questionnaire on that day, but this was not the case. According to Dupont, it can also be assumed
that when each question appears separately on the mobile phone screen and disappears from it
Health Information: What Can Mobile Phone Assessments Add?
immediately after the response is made, the desire to respond is facilitated.8 Since each question appears
separately on a screen, it may promote a more concentrated reflection on the individual issue, while a list
of questions on paper could disrupt the patients’ focus on a single question. On the other hand, perhaps
the patients simply felt more comfortable using the mobile phone.
Similar to our study, Matthew et al. found that when a comparison was made between a paper-based
method and a digital method in a randomized, controlled clinical study, there were fewer missing data
with the digital method, and it was preferred by 82.8 percent of the patients.9 Matthew et al. did not find
any significant correlation between age and difficulty in using the digital method, and neither did we in
this study.10
This study demonstrates that patients found the mobile phone system convenient to use and that it
was not a time-consuming method. A technology-based reminder to assess pain in real time provides
valuable information compared with paper-based surveys that might be answered later, thus requiring the
patient to recall the degree of pain that occurred some time ago. Similarly, Kristjansdottir found that
although the participants were required to answer questions through a digital system several times a day,
it was a user-friendly method.11
The development of such technology for sending and receiving different kinds of health-related
information is at the forefront of quick and secure information exchange. Electronic methods for
individual, patient-reported assessments not only add value over paper-based surveys, but they are also
becoming more acceptable and are perceived as providing a greater degree of confidentiality. When the
participants were randomized into the groups, most of them were interested in the mobile phone system,
and some expressed disappointment on being allocated to the control group. Although some of the older
mobile phones were unable to function with the Medipal program, causing a delay, most of the older
mobile phones were upgraded with the support of Medipal. Nevertheless, a few participants were
excluded since it was not possible to upgrade their mobile phones.
As home-based healthcare increases, including, for example, ambulatory surgery, so-called fast track
surgery, and ERAS, the communication between patients and caregivers needs to be improved.12 The
ongoing self-monitoring of pain and other symptoms by mobile phone appears to be an optimal method
that meets the challenge of following several vital signs in real time.
This method enables caregivers to ensure patient safety and provide optimal access to care through
regular mobile interaction with the patient. Another development will include smartphone applications for
the patients. Rosser and Eccleston found that mobile phone applications can be used for pain education.13
In addition, this mobile technology has been found to be a good distraction technique. A randomized,
controlled study demonstrated that anxiety was significantly reduced in the distraction technique group 45
minutes after operation, compared to the control group.14
Limitations and Areas for Further Study
The small number of participants, which is the main limitation of the study, prevents us from drawing
any established conclusions from analysis of the pain levels. A further significant disadvantage was not
carrying out the follow-up period for the same number of days for both groups. Additional study is thus
necessary.
A further development of this pilot study would be to provide feedback to the patient by sending
appropriate, individual information in real time, for example, details about changing the dosage of
analgesic and improving any symptom control at home. Adequate symptom control can capture pain
variations during the day and describe pain patterns over time as the patient moves about in the normal
daily environment.
Conclusion and Clinical Implications
In this study, it was found that the mobile phone system provided a safe method with which to
measure pain postoperatively in real time. On days 3–4 the mobile group reported significantly higher
6 Perspectives in Health Information Management, Fall 2012
levels of pain than the control group (p < .001). Furthermore, only the mobile phone group reported
additional pain measurements. Patients found the technique easy to use and were willing to use it again.
This project is an adaptation to modern technology and the mobility of individuals. As the use of
mobile phones is expected to increase in the coming years and as their screen size and usability improves,
there is reason to employ this technology more frequently in healthcare, which also helps the patient to
stay mobile. The technology will improve clinical efficiency and care coordination.15
Significant advantages of the mobile phone method for surveys are the real-time measured outcomes,
which are assumed to provide credible, monitored answers of different variables. This real-time
information also facilitates communication between patients and caregivers, which enables them to make
rapid decisions about individual treatment and improve health information.
Acknowledgments
We are grateful to Anna Cederlund and Marcus Smedman for their help.
Margareta Warrén Stomberg, RNA, PhD, is a senior lecturer and associate professor in health
sciences at the University of Gothenburg/Sahlgrenska Academy and Sahlgrenska University
Hospital/Östra in Gothenburg, Sweden.
Birgitta Platon, RNA, is a registered nurse anesthetist in the acute pain team in the gynecology and
obstetrics department at Sahlgrenska University Hospital/Östra in Gothenburg, Sweden.
Annette Widén, CCRN, is a critical care nurse in the acute pain team at Sahlgrenska University
Hospital/Östra in Gothenburg, Sweden.
Ingegerd Wallner, CCRN, is a critical care nurse in the acute pain team at Sahlgrenska University
Hospital/Östra in Gothenburg, Sweden.
Ove Karlsson, MD, is a physician in the anesthesia department at the women’s hospital of
Sahlgrenska University Hospital/Östra in Gothenburg, Sweden.
Margareta Warrén Stomberg, RNA, PhD; Birgitta Platon, RNA; Annette Widén, RN; Ingegerd
Wallner, RN; and Ove Karlsson, MD. “Health Information: What Can Mobile Phone
Assessments Add?” Perspectives in Health Information Management (Fall 2012): 1-10.
Health Information: What Can Mobile Phone Assessments Add?
Notes
1. Segerdahl, M., M. Warrén Stomberg, N. Rawal, M. Brattwall, and J. Jakobsson. “Clinical
Practice and Routines for Day Surgery in Sweden: Results from a Nation-wide Survey.” Acta
Anaesthesiologica Scandinavica 52, no. 1 (2008): 117–24.
2. Gartner, R., M. B. Jensen, J. Nielsen, M. Ewertz, N. Kroman, and H. Kehlet. “Prevalence of
and Factors Associated with Persistent Pain Following Breast Cancer Surgery.” Journal of the
American Medical Association 302, no. 18 (2009): 1985–92.
3. Kehlet, H., T. S. Jensen, and C. J. Woolf. “Persistent Postsurgical Pain: Risk Factors and
Prevention.” Lancet 367, no. 9522 (2006): 1618–25.
4. Kehlet, H., and J. P. Rathmell. “Persistent Postsurgical Pain: The Path Forward through Better
Design of Clinical Studies.” Anesthesiology 112, no. 3 (2010): 514–15.
5. White, P. F., and H. Kehlet. “Improving Postoperative Pain Management: What Are the
Unresolved Issues?” Anesthesiology 112, no. 1 (2010): 220–25.
6. Russ, A. J., L. D. Faucher, D. B. Gordon, T. A. Pellino, and M. J. Schurr. “Functional
Implications of Long-Term Pain Following Outpatient Inguinal Herniorrhaphy—a Prospective
Evaluation.” Journal of Surgical Research 169, no. 1 (2011): 25–30.
7. Dupont, A., J. Wheeler, J. E. Herndon II, A. Coan, S. Y. Zafar, L. Hood, M. Patwardhan, H. S.
Shaw, H. K. Lyerly, and A. P. Abernethy. “Use of Tablet Personal Computers for Sensitive
Patient-Reported Information.” Journal of Supportive Oncology 7, no. 3 (2009): 91–97.
8. Ibid.
9. Matthew, A. G., K. L. Currie, J. Irvine, P. Ritvo, D. Santa Mina, L. Jamnicky, R. Nam, and J.
Trachtenberg. “Serial Personal Digital Assistant Data Capture of Health-Related Quality of Life:
A Randomized Controlled Trial in a Prostate Cancer Clinic.” Health and Quality of Life
Outcomes 5 (2007): 38.
10. Ibid.
11. Kristjansdottir, O. B., E. A. Fors, E. Eide, A. Finset, S. van Dulmen, S. H. Wigers, and H.
Eide. “Written Online Situational Feedback via Mobile Phone to Support Self-Management of
Chronic Widespread Pain: A Usability Study of a Web-based Intervention.” BMC
Musculoskeletal Disorders 12 (2011): 51.
12. Adamina, M., H. Kehlet, G. A. Tomlinson, A. J. Senagore, and C. P. Delaney. “Enhanced
Recovery Pathways Optimize Health Outcomes and Resource Utilization: A Meta-analysis of
Randomized Controlled Trials in Colorectal Surgery.” Surgery 149, no. 6 (2011): 830–40.
13. Rosser, B. A., and C. Eccleston. “Smartphone Applications for Pain Management.” Journal
of Telemedicine and Telecare 17, no. 6 (2011): 308–12.
14. Mosso, J. L., A. Gorini, G. De La Cerda, T. Obrador, A. Almazan, D. Mosso, J. J. Nieto, and
G. Riva. “Virtual Reality on Mobile Phones to Reduce Anxiety in Outpatient Surgery.” Studies
in Health Technology and Informatics 142 (2009): 195–200.
15. Putzer, G., and Y. S. Park. “Are Physicians Likely to Adopt Emerging Mobile Technologies?
Attitudes and Innovation Factors Affecting Smartphone Use in the Southeastern United States.”
Perspectives in Health Information Management (Spring 2012): 1–22.
8 Perspectives in Health Information Management, Fall 2012
Table 1
Participants in the Survey and Their Demographic Characteristics
Type of Surgery
No. of
Participants
Assigned to
Mobile
Phone
Group
No. of
Participants
Assigned to
Control
Group
Estimated
No. of
Patients
Not
Included
Due to
Missing
Support
Function
in Their
Mobile
Phone
No. of
Dropouts
in the
Mobile
Phone
Group
No. of
Dropouts
in the
Control
Group
Mean
Age
(years)
*
(female/
male)
Hysterectomy
10
(5 patients
declined)
10
8
1
(technical
issues)
1
50
Cholecystectomy
10
10
12
0
1
43
* No significant difference, p = .176
Health Information: What Can Mobile Phone Assessments Add?
Figure 1
Flow Chart for the Survey in the Mobile Phone and Control Groups
10 Perspectives in Health Information Management, Fall 2012
Figure 2
Pain at Rest, Days 1–6 Postoperatively: Outcomes Measured through Questionnaires and Mobile
Phone System for Cholecystectomy and Hysterectomy Patients
... Data related to the comparative acceptability of each pain assessment modality were collected in 60% (32/53) studies [5,7,21,22,[24][25][26][27]29,30,34,36,[38][39][40][41][42][47][48][49][50][51][52][53]56,57,60,61,63,64,66,69,72]. Overall, electronic programs to assess pain are highly acceptable to patients. ...
... One study (4%) found no difference in participant satisfaction between electronic and conventional pain instruments [47]. Nine studies did not ask patients to specifically declare a preference for assessment modality but still reported high patient satisfaction with the electronic method [5,7,27,29,48,52,53,56,64,74]. ...
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... This is because patients feel confident to answer questions privately in an anonymous environment. It is also because of the psychological effect that one question appears at a time on a screen, instead of a lengthy list of questions, thus facilitating the patient to focus on each question separately [9]. Analysis of the data recorded by the patient and the provision of results helps patients to analyze the change in pain rating and improvement with time. ...
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... Studies have already demonstrated that using digital health interventions (DHI) can help identify postoperative complications earlier, improve recovery, and provide safe follow-up which is acceptable to patients 10, [14][15][16][17][18] . DHI, defined as 'the use of mobile and wireless technologies for health to improve health system efficiency and health outcomes' 19 , provide the opportunity to connect patients and healthcare providers in real-time. ...
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Full-text available
  • Nov 2017
Background Population cohort studies are useful to study infectious diseases episodes not attended by health care services, but conventional paper diaries and questionnaires to capture cases are prone to noncompliance and recall bias. Use of smart technology in this setting may improve case finding. Objective The objective of our study was to validate an interactive mobile app for monitoring occurrence of acute infectious diseases episodes in individuals, independent of health care seeking, using acute otitis media (AOM) symptom episodes in infants as a case study. We were interested in determining participant compliance and app performance in detecting and ascertaining (parent-reported) AOM symptom episodes with this novel tool compared with traditional methods used for monitoring study participants. Methods We tested the InfectieApp research app to detect AOM symptom episodes. In 2013, we followed 155 children aged 0 to 3 years for 4 months. Parents recorded the presence of AOM symptoms in a paper diary for 4 consecutive months and completed additional disease questionnaires when AOM symptoms were present. In 2015 in a similar cohort of 69 children, parents used an AOM diary and questionnaire app instead. ResultsDuring conventional and app-based recording, 93.13% (17,244/18,516) and 94.56% (7438/7866) of symptom diaries were returned, respectively, and at least one symptom was recorded for 32.50% (n=5606) and 43.99% (n=3272) of diary days (P
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Evaluation of postoperative recovery: past, present and future
Article
  • Apr 2022
  • POSTGRAD MED J
Postoperative recovery, as a window to observe perioperative treatment effect and patient prognosis, is a common outcome indicator in clinical research and has attracted more and more attention of surgeons and anaesthesiologists. Postoperative recovery is a subjective, multidimensional, long-term, complex process, so it is unreasonable to only use objective indicators to explain it. Currently, with the widespread use of patient-reported outcomes, various scales become the primary tools for assessing postoperative recovery. Through systematic search, we found 14 universal recovery scales, which have different structures, contents and measurement properties, as well as their own strengths and weaknesses. We also found that it is urgently necessary to perform further researches and develop a scale that can serve as the gold universal standard to evaluate postoperative recovery. In addition, with the rapid development of intelligent equipment, the establishment and validation of electronic scales is also an interesting direction.
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Use of Mobile-Based Application for Collection of Patient-Reported Outcomes in Cardiac Surgery
Article
  • Nov 2021
Objective Application-based (app) technology has been studied for patient engagement and collecting patient-reported outcomes (PROs) in several surgical specialties with limited research in cardiac surgery. The aim of study was to determine the effectiveness of app-based technology for collecting PROs, improving the patient experience, and reducing health services utilization in a cardiac surgery center. Methods Patients accessed an interactive app via smartphones. Patients were guided from 4 weeks preoperative to 4 weeks postoperative via reminders, tasks, PRO surveys, and evidence-based education. In the postoperative period, patients were engaged with daily health surveys to track warning signs and recovery milestones. Based on the patient's signs and symptoms, the app escalated lower risk issues to self-care education or higher risk issues to the care team (e.g., phone call to a nurse). Results Sixty-six percent of patients (730 of 1,108) activated their app account. Two hundred seventy-seven patients completed an end-of-program feedback survey, with 94% of patients recommending the app and 98% of patients finding the app was helpful in recovery. Patients also reported using the app to avoid unnecessary health services utilization, with 45% of patients using the app to avoid at least 1 phone call and 28% of patients using the app to avoid at least 1 hospital visit. Conclusions App-based technology for patient engagement is an effective modality to enhance the patient experience, better understand the trajectory of recovery, and reduce unnecessary health services utilization in cardiac surgery.
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Automated Mobile Phone Messaging Utilizing a Cognitive Behavioral Intervention: A Pilot Investigation
Article
Full-text available
  • Jan 2019
Background: In the setting of outpatient orthopaedic surgery, this pilot study utilized automated mobile messaging to assess (1) the feasibility of and interaction rates with a software delivered cognitive behavior therapy (CBT) intervention for postoperative opioid utilization, (2) the reliability of patient reported opioid utilization through our platform, (3) daily patient reported pain and opioid utilization within the first two postoperative weeks, and (4) the effect of software delivered CBT intervention on patient reported opioid utilization. Methods: Musculoskeletal tumor patients scheduled for outpatient surgery were randomized into two study groups. Control patients received standard postoperative communication limited to a two-week postoperative follow-up visit. The intervention group received automated daily text-messages regarding pain, opioid utilization, and a daily CBT intervention. Interventional group patients also completed a patient satisfaction questionnaire at their two-week follow-up. Completion rates of all software delivered questions were determined in the interventional group. Median values of opioid utilization and interquartile range (IQR) were determined to compare utilization between groups. Spearman correlation coefficients were used to determine reliability of patient reported opioid utilization in the interventional group. Results: Fourteen patients completed the pilot study (seven controls, seven intervention). Patients in the intervention arm completed 90% of pain and opioid questions. Intervention group patients utilized less of their daily prescribed opioid medication (20%, IQR:10%-27%) compared to controls (50%, IQR:4%-68%). Correlation between in-office pill counts and patient reported opioid medication utilization via our software messaging system was high (r=0.90, p=0.037). Conclusion: Automated mobile phone messaging in outpatient tumor surgery yielded high interaction rates. Patient reported opioid utilization obtained through our platform demonstrated a high correlation with in-office pill counts. CBT delivered via automated mobile phone messaging demonstrated decreased opioid utilization in this pilot investigation.Level of evidence: II.
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Gains and limitations of a connected tracking solution in the perioperative follow-up of colorectal surgery patients
Article
  • Feb 2020
Objective: The means to target shorter hospital stay includes information technology strategies to improve communication between caregivers and patients in order to limit potentially avoidable readmissions. The aim of the present study was to analyse the benefits and limitations of a smartphone-based connected tracking solution in the perioperative follow-up of colorectal surgery patients. Materials and methods: Retrospective monocentric cohort study of consecutive patients after colorectal surgery between February and December 2018. The mobile health application included information delivery and daily structured questionnaires on a personalized patient electronic profile, before the hospital stay and for 7 days post-discharge. The medical team answered automatic alerts in real-time. Results: A total of 93 eligible patients were approached and 36 had to be excluded (26: no smartphone, 5: no email, 5: not French speaking). Among the potential users, 50 (88%) engaged in a mHealth app and 7 refused. Of these 50 patients, 7 dropped out. Of the remaining 43 patients, the app detected 12 adverse events, and 10 (83%) were handled through the app. Health care providers responded to patient-generated alerts after a median time of 90 minutes (range: 9-448 minutes). Patients' mean satisfaction level was 4±0.97 out of 5. Conclusion: In total, 88% of smartphone-equipped patients showed a willingness to engage in mHealth. Reasons for exclusion were the absence of connection tools and a language barrier. Patients who responded to the survey were satisfied with the solution and 83% of post-discharge adverse events were solved through the app, avoiding emergency consultations.
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m-Health in the Surgical Context: Prospecting, Review and Analysis of Mobile Applications
Article
Full-text available
  • Jan 2019
  • Open Nurs J
Background m-Health initiatives can show an opportunity to improve the identification, prevention and management of certain diseases. Most health-care applications aims at chronic noncommunicable diseases care, and it is necessary to seek evidence from applications intended for surgical patient care, either before, during or after hospitalization. Objective The Study Aims to identify and analyze, from the literature review and prospecting, applications for smartphones developed to assist the surgical patient. Methods A descriptive-exploratory study developed in two sequential phases. The first one corresponded to an integrative review of the literature in the databases PubMed, Web of Knowledge, Europe PMC database and Cumulative Index to Nursing and Allied Health Literature database. The second phase corresponded to an exploration of applications in the European Patent Office, United States Patent and Trademark Office (USPTO), Free Patents Online, Canadian Intellectual Property Office and World Intellectual Property Organization. In both phases, we do not restrict the results by year of publication/registration or language. At each stage, the selected studies/patents were analyzed and pre-selected, according to the inclusion and exclusion criteria, by reading their titles and abstracts. Subsequently, we analyzed those with the potential of participation in the study, evaluating the answer to the research question, as well as the type of research, objectives, sample, method, outcomes, results and conclusion. Finally, the articles/patents record found were read in full. Results In the databases, 14 studies that presented some application for smartphone aimed at the surgical patient were selected. Most of them were in PubMed (64.3%), published in English (100%). Regarding origin, 28.6% of the texts are from the United States of America, 14.3 from Sweden and 14.3 from Canada. On the other hand, in patent databases, 10 registries were selected, 60% in the USPTO patent base, hosted in hybrid systems (iPhone and Android) and developed in the last 5 years (2014-1018) (80%). In general, there is a series of applications aimed at surgical patients, such as targets and/or users, mainly focused on the exchange of text and image messages but concentrated on assisting the physician/health team in the preparation of the patient during the procedure or post discharge. It is necessary to invest in the creation of technologies that aim to monitor these patients, especially in post discharge. Conclusion The characteristics of applications indicate a strong hospital centered tendency in relation to its purpose, having the surgeon as the main user and the surgical patient as the main target. The applications are still focused on optimizing diagnostics or functions, and no initiatives are identified to monitor the patient in a non-hospital environment.
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Individualised Nursing Care of Operative Surgical Patients: Theory, Measurement, Research and Practice
Chapter
  • Jan 2019
The purpose of this chapter is to describe the nature and implementation of individualised nursing care among surgical patients. The nature of this care is operational, the patient-professional contact is short and the emphasis is on supporting recovery and self-management by educational activities. In this chapter, we first describe the nature of individualised surgical nursing care and then move on to the support of this care. © Springer International Publishing AG, part of Springer Nature 2019.
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Written Online Situational Feedback Via Mobile Phone to Support Self-Management of Chronic Widespread Pain: A Usability Study of a Web-Based Intervention
Article
Full-text available
  • Feb 2011
  • BMC MUSCULOSKEL DIS
This pretrial study aimed to develop and test the usability of a four-week Internet intervention delivered by a Web-enabled mobile phone to support self-management of chronic widespread pain. The intervention included daily online entries and individualized written feedback, grounded in a mindfulness-based cognitive behavioral approach. The participants registered activities, emotions and pain cognitions three times daily using the mobile device. The therapist had immediate access to this information through a secure Web site. The situational information was used to formulate and send a personalized text message to the participant with the aim of stimulating effective self-management of the current situation. Six women participated and evaluated the experience. The intervention was rated as supportive, meaningful and user-friendly by the majority of the women. The response rate to the daily registration entries was high and technical problems were few. The results indicate a feasible intervention. Web-applications are fast becoming standard features of mobile phones and interventions of this kind can therefore be more available than before. ClinicalTrials.gov: NCT01236209.
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Use of tablet personal computers for sensitive patient-reported information
Article
Full-text available
  • Nov 2008
  • J Support Oncol
Notebook-style computers (e/Tablets) are increasingly replacing paper methods for collecting patient-reported information. Discrepancies in data between these methods have been found in oncology for sexuality-related questions. A study was performed to formulate hypotheses regarding causes for discrepant responses and to analyze whether electronic data collection adds value over paper-based methods when collecting data on sensitive topics. A total of 56 breast cancer patients visiting Duke Breast Clinic (North Carolina) participated by responding to 12 subscales of 5 survey instruments in electronic (e/Tablet) format and to a paper version of 1 of these surveys, at each visit. Twenty-one participants (38%) provided dissimilar responses on paper and electronic surveys to one item of the Functional Assessment of Cancer Therapy-General (FACT-G) Social Well-Being scale that asked patients to rate their satisfaction with their current sex life. Among these 21 patients were 8 patients who answered the question in the electronic environment, and 13 patients who answered both paper and electronic versions but with different responses. Eleven patients (29%) did not respond to the item on either e/Tablet or paper; 45 patients (80%) answered it on e/Tablet; and 37 patients (66%) responded on the paper version. The e/Tablet electronic system may provide a "safer" environment than paper questionnaires for cancer patients to answer private or highly personal questions on sensitive topics such as sexuality.
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Virtual reality on mobile phones to reduce anxiety in outpatient surgery
Article
Full-text available
  • Feb 2009
  • Stud Health Tech Informat
When undergo ambulatory surgical operations, the majority of patients experience high level of anxiety. Different experimental studies have shown that distraction techniques are effective in reducing pain and related anxiety. Since Virtual reality (VR) has been demonstrated a good distraction technique, it has been repeatedly used in hospital contexts for reducing pain in burned patients, but it has never been used during surgical operations. With the present randomized controlled study we intended to verify the effectiveness of VR in reducing anxiety in patients undergoing ambulatory operations under local or regional anaesthesia. In particular, we measured the degree to which anxiety associated with surgical intervention was reduced by distracting patients with immersive VR provided through a cell phone connected to an HMD compared to a no-distraction control condition. A significant reduction of anxiety was obtained after 45 minutes of operation in the VR group, but not in the control group and, after 90 minutes, the reduction was larger in the experimental group than in other one. In conclusion, this study presents an innovative promising technique to reduce anxiety during surgical interventions, even if more studies are necessary to investigate its effectiveness in other kinds of operations and in larger numbers of patients.
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Are physicians likely to adopt emerging mobile technologies? Attitudes and innovation factors affecting smartphone use in the Southern United States
Article
  • Jun 2012
The smartphone has emerged as an important technological device to assist physicians with medical decision making, clinical tasks, and other computing functions. A smartphone is a device that combines mobile telecommunication with Internet accessibility as well as word processing. Moreover, smartphones have additional features such as applications pertinent to clinical medicine and practice management. The purpose of this study was to investigate the innovation factors that affect a physician's decision to adopt an emerging mobile technological device such as a smartphone. The study sample consisted of 103 physicians from community hospitals and academic medical centers in the southeastern United States. Innovation factors are elements that affect an individual's attitude toward using and adopting an emerging technology. In our model, the innovation characteristics of compatibility, job relevance, the internal environment, observability, personal experience, and the external environment were all significant predictors of attitude toward using a smartphone. These influential innovation factors presumably are salient predictors of a physician's attitude toward using a smartphone to assist with clinical tasks. Health information technology devices such as smartphones offer promise as a means to improve clinical efficiency, medical quality, and care coordination and possibly reduce healthcare costs.
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Smartphone application for pain management
Article
  • Aug 2011
  • J TELEMED TELECARE
Smartphone applications (or apps) are becoming increasingly popular. The lack of regulation or guidance for health-related apps means that the validity and reliability of their content is unknown. We have conducted a review of available apps relating to the generic condition of pain. The official application stores for five major smartphone platforms were searched: iPhone, Android, Blackberry, Nokia/Symbian and Windows Mobile. Apps were included if they reported a focus on pain education, management or relief, and were not solely aimed at health-care professionals (HCPs). A total of 111 apps met the inclusion criteria. The majority of apps reviewed claimed some information provision or electronic manual component. Diary tracking of pain variables was also a common feature. There was a low level of stated HCP involvement in app development and content. Despite an increasing number of apps being released, the frequency of HCP involvement is not increasing. Pain apps appear to be able to promise pain relief without any concern for the effectiveness of the product, or for possible adverse effects of product use. In a population often desperate for a solution to distressing and debilitating pain conditions, there is considerable risk of individuals being misled.
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Enhanced recovery pathways optimize health outcomes and resource utilization: A meta-analysis of randomized controlled trials in colorectal surgery
Article
  • Jun 2011
Health care systems provide care to increasingly complex and elderly patients. Colorectal surgery is a prime example, with high volumes of major procedures, significant morbidity, prolonged hospital stays, and unplanned readmissions. This situation is exacerbated by an exponential rise in costs that threatens the stability of health care systems. Enhanced recovery pathways (ERP) have been proposed as a means to reduce morbidity and improve effectiveness of care. We have reviewed the evidence supporting the implementation of ERP in clinical practice. Medline, Embase, and the Cochrane library were searched for randomized, controlled trials comparing ERP with traditional care in colorectal surgery. Systematic reviews and papers on ERP based on data published in major surgical and anesthesiology journals were critically reviewed by international contributors, experienced in the development and implementation of ERP. A random-effect Bayesian meta-analysis was performed, including 6 randomized, controlled trials totalizing 452 patients. For patients adhering to ERP, length of stay decreased by 2.5 days (95% credible interval [CrI] -3.92 to -1.11), whereas 30-day morbidity was halved (relative risk, 0.52; 95% CrI, 0.36-0.73) and readmission was not increased (relative risk, 0.59; 95% CrI, 0.14-1.43) when compared with patients undergoing traditional care. Adherence to ERP achieves a reproducible improvement in the quality of care by enabling standardization of health care processes. Thus, while accelerating recovery and safely reducing hospital stay, ERPs optimize utilization of health care resources. ERPs can and should be routinely used in care after colorectal and other major gastrointestinal procedures.
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Functional Implications of Long-Term Pain Following Outpatient Inguinal Herniorrhaphy—A Prospective Evaluation
Article
  • Jul 2011
  • J SURG RES
The purpose of the present study is to assess pain and functional outcomes at 1 y following inguinal herniorrhaphy in which patients were randomized to receive a continuous wound infusion of bupivacaine to receiving a saline infusion. Patients received saline or bupivacaine prior to incision and then for 60 h postoperatively. The incidence, severity, and functional interference of pain were assessed for five postoperative days, and at 1 y. Seventy patients completed a survey 1 y following herniorrhaphy. Four percent (3/72) of patients were in moderate to severe pain "almost always" or "often". Twenty-one percent (15/72) of patients experienced pain with ambulation. There was no difference between groups at 1 y. The incidence of moderate or severe pain is concerning 1 y following surgery. Functional aberrations associated with pain should be assessed in all studies evaluating long-term pain after herniorrhaphy.
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Improving Postoperative Pain Management: What Are the Unresolved Issues?
Article
  • Dec 2009
  • ANESTHESIOLOGY
Despite the tremendous progress that has been made in our understanding of the pathophysiologic basis of acute pain, there remains a need for clinicians to implement evidencebased procedure-specific multimodal analgesic protocols, which are modified to meet the needs of individual patients to enhance the quality of postoperative pain management. Importantly, there is a critical need for collaborations between the various heathcare providers involved in perioperative patient care (e.g., anesthesiologists, surgeons, nurses, and physiotherapists) to integrate improved perioperative pain management with the recently described fast-track recovery paradigms.14,15 This type of combined approach is well documented to improve the quality of the recovery process and reduce the hospital stay and postoperative morbidity, leading to a shorter period of convalescence after surgery. Rather than simply performing more meta-analysis and systematic reviews of the pain management literature,12 clinical investigators need to return to the hard work of performing prospective, randomized clinical trials on a procedure-specific basis, evaluating the use of different analgesic combinations as part of multimodal analgesic treatment regimens in the postoperative period.
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Prevalence of and Factors Associated With Persistent Pain Following Breast Cancer Surgery
Article
  • Nov 2009
  • J Am Med Assoc
Persistent pain and sensory disturbances following surgical treatment for breast cancer is a significant clinical problem. The pathogenic mechanisms are complex and may be related to patient characteristics, surgical technique, and adjuvant therapy. To examine prevalence of and factors associated with persistent pain after surgical treatment for breast cancer. A nationwide cross-sectional questionnaire study of 3754 women aged 18 to 70 years who received surgery and adjuvant therapy (if indicated) for primary breast cancer in Denmark between January 1, 2005, and December 31, 2006. A study questionnaire was sent to the women between January and April 2008. Prevalence, location, and severity of persistent pain and sensory disturbances in 12 well-defined treatment groups assessed an average of 26 months after surgery, and adjusted odds ratio (OR) of reported pain and sensory disturbances with respect to age, surgical technique, chemotherapy, and radiotherapy. By June 2008, 3253 of 3754 eligible women (87%) returned the questionnaire. A total of 1543 patients (47%) reported pain, of whom 201 (13%) had severe pain, 595 (39%) had moderate pain, and 733 (48%) had light pain. Factors associated with chronic pain included young age (18-39 years: OR, 3.62; 95% confidence interval [CI], 2.25-5.82; P < .001) and adjuvant radiotherapy (OR, 1.50; 95% CI, 1.08-2.07; P = .03), but not chemotherapy (OR, 1.01; 95% CI, 0.85-1.21; P = .91). Axillary lymph node dissection (ALND) was associated with increased likelihood of pain (OR, 1.77; 95% CI, 1.43-2.19; P < .001) compared with sentinel lymph node dissection. Risk of sensory disturbances was associated with young age (18-39 years: OR, 5.00; 95% CI, 2.87-8.69; P < .001) and ALND (OR, 4.97; 95% CI, 3.92-6.30; P < .001). Pain complaints from other parts of the body were associated with increased risk of pain in the surgical area (P < .001). A total of 306 patients (20%) with pain had contacted a physician within the prior 3 months for pain complaints in the surgical area. Two to 3 years after breast cancer treatment, persistent pain and sensory disturbances remain clinically significant problems among Danish women who received surgery in 2005 and 2006.
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