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Consumer health care technology shows potential to improve outcomes for community-dwelling persons with chronic conditions, yet health app quality varies considerably. In partnership with patients and family caregivers, hospital clinicians developed Care4myHeart, a mobile health (mHealth) app for heart failure (HF) self-management.
The aim of this paper was to report the outcomes of the nurse-led design process in the form of the features and functions of the developed app, Care4myHeart.
Seven patients, four family caregivers, and seven multidisciplinary hospital clinicians collaborated in a design thinking process of innovation. The co-design process, involving interviews, design workshops, and prototype feedback sessions, incorporated the lived experience of stakeholders and evidence-based literature in a design that would be relevant and developed with rigor.
The home screen displays the priority HF self-management components with a reminder summary, general information on the condition, and a settings tab. The health management section allows patients to list health care team member’s contact details, schedule medical appointments, and store documents. The My Plan section contains nine important self-management components with a combination of information and advice pages, graphical representation of patient data, feedback, and more. The greatest strength of the co-design process to achieve the design outcomes was the involvement of local patients, family caregivers, and clinicians. Moreover, incorporating the literature, guidelines, and current practices into the design strengthened the relevance of the app to the health care context. However, the strength of context specificity is also a limitation to portability, and the final design is limited to the stakeholders involved in its development.
We recommend health app development teams strategically incorporate relevant stakeholders and literature to design mHealth solutions that are rigorously designed from a solid evidence base and are relevant to those who will use or recommend their use.
The management of chronic conditions is an important public health challenge [
In an era of rapid technological advancement, there is a growing interest in consumer digital health to help with improving health. Out of the 318,000 plus mobile health (mHealth) applications (apps) available to consumers across the world [
From the health provider perspective, the lack of evidence regarding the effectiveness of mHealth apps to improve health care outcomes limits their addition to treatment protocols [
If we are to embrace consumer digital health care for its potential to address the burden of chronic conditions, interventions need to be well designed, evidence-based, and fit-for-purpose for health care providers and health care consumers alike. With this in mind, the aim of this research was to use co-design processes to develop a consumer mHealth intervention for HF self-management that is both relevant to stakeholders and developed with rigor. This paper reports the outcomes of the nurse-led design process in the form of the features and functions of the developed app,
This research was informed by the Design Science Research Cycles proposed by Hevner [
The systematic design and development followed the Stanford University’s Design Thinking Process of innovation [
Interviews were conducted with 7 patients, 4 family caregivers, and 7 clinicians to identify experiences, challenges, and opportunities regarding the lived experience of the main stakeholders. The following design artefacts—material objects that can be viewed by others, used to challenge perceptions, and inspire new ideas [
Journey map: a list of daily self-care activities and associated emotional responses.
Stakeholder map: personal and professional persons involved in self-care.
Personas: 4 diverse characters representing patient needs and insights [
Current care summary: health professional’s critique of self-care support [
Clinical relevance information: considerations for the effective implementation of the mHealth app [
The design brief was developed by the research team (authors 1, 2, 4, and 5) from analyzing the design artefacts. It is a result of the composite of the design artefacts as interpreted by the research team. The design priorities within the brief were to (1) address medication and symptom management challenges, (2) involve some form of self-care plan, and (3) manage all stakeholders in care, as well as being evidence-based, useful, simple, and easy to use [
A subset of 11 participants representing each of the three stakeholder groups (seven clinicians, three patients, one family caregiver) participated in two workshops and 4 months of iterative prototype development in 2017 [
The findings elicited throughout the co-design process are reported alongside each app component in a justification of the final app design. First, we present an overview of the app and thereafter describe the app’s 3 main sections.
The three main sections of the app are described further with a description of the rationale behind the design.
The Care4myHeart home screen including the health management section (boxed in orange).
The Care4myHeart app "My Plan" section.
Care4myHeart’s home screen design and rationale.
Subsection | Item | Rationale |
My Plan icons | Nine self-management components; |
Design priority to involve some kind of self-care plan; clinicians wanted individualized care plan which involves the patient and family; standards [ |
Heart failure information | Information pages: overview, symptoms, and treatments | Design priority to have an evidence-based resource that would be useful, simple, and easy to use; clinicians wanted early, regular, clear, appropriate, basic, and needs-based educational material; health literacy considerations; the credible source for the information was the St Vincent’s Heart Health website [ |
Today’s alerts | List of tasks to be completed | The literature highlights the key measures to track in HF and the importance of setting self-care goals [ |
Settings | Enter baseline data and set goals | The team referred to the key measures to track in HF and recommendations to set self-care goals [ |
aHF: heart failure.
This subsection is based on the principles within the Australian standards [
HF information, written in plain English including an overview of the condition, common symptoms, and treatments, is found via a button on the home screen accessible by patients and their family. The information was sourced from the St Vincent’s Heart Health website [
A summary list of self-management tasks for the user to complete for the day (today’s alerts) was a priority design inclusion. Local clinicians believed that follow-up with patients should be improved in current care to aid memory. The co-design team members considered reminders and scheduling important functions of the app to be addressed and are, therefore, included features in the alerts summary.
Baseline self-management data and patient goals are personalized in the app’s settings. The co-design team members prioritized patient ownership, interactivity, and tracking as important for the user experience. In the app settings, the key measures to track [
The
The health management section design and rationale.
Subsection | Item | Rationale |
Appointments | Add medical appointments including detail | Patients experienced challenges managing multiple appointments with family caregivers often assisting; clinicians believed follow-up and connected care is not done well in the health service; scheduling and reminders were a priority; reviewed current tools for documenting clinic and doctor visits [ |
My Docs | Store, review, and share test results, letters, and referrals | Some patients wanted test results but may misplace documentation; clinicians wanted to include or track data, facilitate team communication, and maximize and join care; reviewed tools to document health records [ |
My Team | Contact details of emergency contact person and health professionals | Patients frequently liaise with their health care team but experience poor information sharing between health care providers; a design priority was to manage all stakeholders in care well and facilitate team communication; referred to the recommendations [ |
aHF: heart failure
The appointments tab contains a calendar to add, review, and set reminders for medical appointments with the ability to add detail needed for the appointment. The HF self-management literature lists the importance of keeping track of clinic and doctor visits [
The My Docs (documents) section provides an opportunity to store, review, and share test results, letters, and referrals. Documenting health records [
My Team lists the contact details of the user’s emergency contact person and the health professionals relevant to their care. The recommendations [
This section includes nine subsections of HF self-management, and the favorites option and is summarized in
The My Plan section design and rationale.
Subsection | Item | Rationale |
Symptoms | Infographic of common signs and symptoms; help seeking information; understanding deterioration information | Patients reported frequent, varied symptoms. Some were frustrated by multiple, interacting, and complex symptoms or lacked understanding of the treatment rationale in lessening symptom burden; the design brief highlighted the importance of addressing symptom management challenges; the co-design team wanted information and self-help which is visual and simple; source of the infographic was the St Vincent’s Heart Health website [ |
Medications | Medication, previous medications, and allergy list; medicine information; diuretic plan | Clinicians believed medication management should be better supported; patients reported challenges with managing their medications with caregivers often involved; medication information was an important design feature, with specific insights and expertise provided by the pharmacist; the team referred to HF medicine information in patient education booklets [ |
Fluid | Visual representation of jug at volume of fluid restriction; user enters oral fluid intake throughout the day | Patients experienced challenges with maintaining fluid restrictions; the co-design team wanted tracking with feedback and an interactive interface; fluid-related HF information and advice [ |
Diet | Healthy eating; low salt (sodium) eating including label reading and foods to avoid | Patients wanted general information only; caregivers often prepare meals; specific insights and expertise were provided from the clinical dietitian on the co-design team; information and advice on healthy eating including reducing salt [ |
Weight | Record daily weight with 7-day graph; interactive, color-coded feedback and pop up alerts | Patients may not be accurate or remember their daily weight; clinicians wanted to include or track HF-related data in an interactive, visual, and tailored format; the cardiac nurse consultant mainly designed the feedback system; information on fluid retention including documenting daily weight and guidelines for help seeking were referred to [ |
Blood pressure (BP) and Pulse | Record and store BP and pulse measurements | A patient suggested this subsection and the cardiologist supported its inclusion; patient booklets supported intermittent documentation of BP [ |
My Future | Information and prompts to |
Clinicians suggested the inclusion of information on advance care planning; the team referred to the local advance care planning website [ |
Well-being | Interactive depression screening tool; |
This subsection was suggested by a patient; patients frequently reported anxiety and worry; emotional support was a priority function; the team reviewed the local depression screen tool (Patient Health Questionnaire-2, PHQ-2 score) in use at the hospital [ |
Exercise | Step counter with 7-day graph; 3× exercise videos demonstrated by physiotherapist (balance, upper limb, and lower limb) with 7-day graph | Patients reported using their smartphone’s step counter, appreciated supervised physical exercise, and set their own exercise goals; clinicians wanted to include or track data; the physiotherapist designed the exercise program, using the Otago exercise program [ |
aHF: Heart failure.
This subsection includes an infographic containing the common signs and symptoms of HF, information to assist in appropriate help seeking, and information about worsening HF. This subsection was an important inclusion in the app because patients frequently reported symptoms such as breathlessness, urinary frequency, sleep disturbance, fatigue, exhaustion and nighttime breathlessness, anxiety, and agitation. Patients said they were frustrated by multiple, interacting, and complex symptoms. Other patients lacked understanding of the treatment rationale in lessening symptom burden. During workshop activities, the co-design team decided it was a design priority to include information and self-help in a visual and simple format. The infographic representing common HF symptoms was sourced, with approval, from the St Vincent’s Heart Health website [
The medication component includes a list of current medications, previous medications, an allergy list, medicine information, and the patient’s own diuretic plan. Clinicians thought it appropriate to facilitate improved medication management as a component that should be improved in current care. The pharmacist on the co-design team provided specific insight into the design of this subsection. Patients reported the disruption to their routine when medication prescriptions were changed and the inconsistent documenting of medication lists with some writing changes on scrap paper or even forgetting important changes in the reality of daily life. Family caregivers are sometimes involved in reminders, and patients reported taking tablets with them during outings; so, these realities of the daily management of medications were incorporated into the design of this subsection. During workshop activities where the subsection was further refined, the co-design team members prioritized medication information as an important design feature. The cardiac nurse consultant regularly caring for indigenous Australians saw value in including the color of the medication as a visual reminder. In regard to the literature, medication is a reported important component of HF self-management as per the information contained within the patient education booklets [
This subsection comprises of the important fluid restriction guideline for HF. The page displays a visual representation of a measuring jug at the volume of fluid restriction tailored to the patient’s restriction volume in the settings (commonly 1200 mL or 1500 mL per day). The jug gradually fills as users enter oral fluid intake throughout the day. Restricting fluid intake is likely the most important method to prevent fluid congestion alongside taking diuretic medications; however, patients commonly reported challenges with maintaining fluid restrictions in daily life, especially with thirst. Clinicians wanted to include or track data, and during design workshops, the co-design team emphasized that user feedback and an interactive interface were important. Information and advice [
The diet component includes information for healthy eating, low salt (sodium) eating, label reading, and foods to avoid. Patients reported that they were not necessarily interested in calorie counting, so general information and advice on healthy eating including reducing salt [
Daily weight management in this subsection of the app gives the user the ability to record daily weight, view a 7-day weight trend on a bar graph, receive color-coded feedback based on this data and pop up alerts depending on stability of that day’s weight in comparison to the dry weight set in the settings tab. Information on fluid retention including documenting daily weight and guidelines for help seeking [
For some, self-monitoring of BP and pulse is important in HF. This
This subsection relates to the long-term planning required for patients with HF. This section contains information and prompts to decide on a plan, discuss this with others, speak to their doctor, and plan what happens to their defibrillator (an implantable medical device) if they have one. The inclusion of this section was deemed relevant by clinicians, and patients on the co-design team agreed to its inclusion without providing specific input into its content. The team reviewed the local advance care planning website [
The well-being component represents the psychological aspect of self-management. It contains an interactive depression screening tool,
The exercise component has a step counter with 7-day graphical representation of daily steps. There was an inclusion of 3 exercise videos demonstrated by the physiotherapist—balance, upper limb, and lower limb—with a 7-day graph. Patient interviews uncovered that patients were using their smartphone’s step counter, appreciate supervised physical exercise and set exercise goals, for example one patient setting a 2 km daily walk. Clinicians valued ability to track patient data in considering the relevance to the patient group, and physiotherapist on the co-design team designed the exercise program to the specific context. The Otago exercise program to prevent falls in older adults [
We have presented the final design of the
The greatest strength of the co-design process to achieve the design outcomes was the involvement of clinicians, patients, and family caregivers. Drawing on best practice, the literature supports using collaborative, team-based processes to develop mHealth interventions [
First, in the empathize and define phase, stakeholders were individually interviewed to understand their experiences, ensuring perspectives and opinions were appropriately defined. Appreciating the various interests of different stakeholders [
Second, bringing stakeholders together was beneficial in the ideation phase for a fit-for-purpose design. Collaborative practices support design features that would be accepted by potential users and are technically feasible [
Finally, in the prototype phase, all stakeholders provided feedback independently to refine the wireframes. The overarching principal was that the design reflected the ideas generated by the group [
Another noteworthy contribution of this research was incorporating the literature, guidelines, and current practices into the design which strengthened the relevance of the app to the health care context. Clinicians aspired to develop this app as a self-management tool to be an adjunct offering in addition to existing HF care. To support clinicians in providing the expert care they aspired to provide, they were unanimous, it needed to include the locally relevant evidence-based information and be consistent with the self-management support literature they provide. The app aimed to supplement (not replace) other traditional formats of patient education (eg, patient information booklets [
The outcomes of the design are limited by the stakeholders involved in the project. Each person had a role to play to positively impact the final design but also the potential to limit the design. For example, the nurse lead who facilitated the design activities had limited design experience and, thus, learned co-design processes as the project developed. A skilled facilitator in co-design chooses the right tools and provides the right environment to engage and inspire [
The strength of context specificity is also a limitation of the portability of the design. The Australian policy and current practices and procedures were included to address the needs of the local health care environment. Therefore, extra work in the design will be required to make the app relevant outside of the community in which it was designed, to be aligned with other health care environments and consumer needs.
The first step is assessing patients’ acceptance of such a tool to their current lifestyle. This research team has undertaken a usability study aimed to understand the experience of using the app with new subset of patients not involved in the design phase. Findings from the usability study will determine other features for inclusion in the next version and provide implications of consumer mHealth apps to self-management practices.
Co-design processes for context-specific digital health, particularly with the involvement of multiple stakeholders, should be evaluated for effectiveness. Currently, researchers are interrogating the process from the perspective of co-design participants and the nurse lead.
In this paper, the final, modular design of the consumer mHealth app for HF,
blood pressure
heart failure
mobile health
Patient Health Questionnaire-2
The authors would like to thank the patients, family members, and clinicians for contributing their time and feedback in the development process. This research is supported by a St Vincent’s Clinic Foundation grant and a scholarship from the District Nurses, Hobart.
None declared.