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Efficient digitization in medicine still is in its infancy but undeniably has great potential for current and future challenges in health care. Thus far, the rollout of medical apps has not resulted in widespread use of smartphones in the German health care sector—the reasons for this have not been clarified so far. Nevertheless, the lack of user involvement in the development process and content creation might contribute to low acceptance of these products.
This study aims to outline an approach to involve medical expertise without any coding knowledge for developing medical app content and functions.
An end user–operable backend was built. Its usability was evaluated using a usability evaluation test protocol. The results of the usability tests were evaluated by the app development team, and the usability test was repeated for optimizing backend usability. In total, 40 criteria to measure the ease of app usage were defined a priori. The usability test comprised 20 tasks that had to be fulfilled. Usability tasks were analyzed for completion, dropout, and test duration. Due to the COVID-19 pandemic, digital videoconferencing platforms (Zoom and QuickTime Player) were used to complete usability questionnaires. Finally, several backend-based apps for several specialties (infectiology, plastic and reconstructive surgery, and orthopedics) were developed by health care professionals as prototypes.
Initial usability testing was conducted with 5 participants (4 men and 1 woman; mean age 39.2, SD 5.97 years). All of them could complete the assigned backend tasks with only a few workflow interruptions and some minor errors. After usability optimization, the workflow completion time decreased from 5.03 minutes to 3.50 minutes, indicating a time saving. The basic backend structure was clear to all test users and the handling was intuitive to learn. Some minor errors in the backend occurred during the test rounds. The apps developed using the aforementioned approach are in clinical use as a proof of concept.
Backends offering operability for medical professionals might have great potential for app development in the mobile health sector. Sophisticated and time-saving usability are pivotal for the acceptance of medical software, as illustrated by the backend-based apps presented herein, which are in clinical use as a proof of concept. Basic interventions are essential and sufficient for adequate usability optimization. Practicable, well-structured software usability evaluation is possible based on the usability evaluation test protocol.
Since the introduction of smartphones in 2007, they have rapidly gained popularity and are omnipresent nowadays [
Digitization in medicine is still lacking but undeniably has major potential for current and future challenges in health care [
Apps focusing on the flow of information to optimize patient education might help to support patients in their health issues. However, only few medical professionals (MPs) and patients reported previous medical app usage [
To increase the involvement of health care professionals in app development, this study outlines an approach to develop app content and function without any coding knowledge. As a first step, a specific methodology was established to ensure end user operability of the backend by developing a user-friendly interface. As a second step, multiple app prototypes in use by health care professionals and patients were developed with the backend-based DCMS—these are presented as a proof of concept. The introduction of the potential and functionality of backends might inspire more adaptable mobile health (mHealth) solutions for digitizing the health care sector.
A multidisciplinary team was involved in the development process of the software. The team comprised 2 physicians (FD and SB), a lawyer, a user experience (UX) designer, and a software and web developer. The backend server runs on a web-based app based on the hypertext preprocessor framework Symfony and meets software security guidelines (eg, the International Organization for Standardization/ International Electrotechnical Commission standard 27001 of 2013, standard 27017 of 2015, standard 27018 of 2019, standard 27701 of 2019, and standard 9001 of 2015). All server structures are located in Germany. No patient-related data were obtained. The backend works as a DCMS and supports the digitization of larger data sets. Different functions can be performed via the backend that directly modifies the linked app’s design and functionality (frontend). For example, not only text but also font size, style, and color can be added or changed in the backend. Links, images, and videos can also be integrated. Any data exchange between the backend and apps runs via a secure sockets layer–secured connection. DCMS-corresponding apps were developed using React Native (Facebook Inc) technology. React Native is a Javascript-based framework for software developers, building cross-platform mobile apps for Android or iOS devices. The framework features built-in components and application programming interfaces, which are essential for developing innovative and user-friendly mobile apps [
Before starting the software development process, patients’ and physicians’ preferences for medical apps were elicited [
The DCMS development flowchart. *Backend-based stand-alone apps include individual functions, a unique app logo, and the implementation of individual corporate designs. The development process is more efficient than the alternative of “starting from scratch” with every app because a modular build system can be used. **A contentless system app with predefined functions, which communicates with the backend, is even simpler. The empty app could be adapted to the respective requirements via the backend and transferred to the system app via QR codes or links, which would then personalize itself. DCMS: data content management system; mHealth: mobile health; UX: user experience.
Visualization of one action path for the test users by using templates. The mechanism from the content edit box to the in-screen simulation is shown.
After completion of the beta backend programming, a UX evaluation test protocol was developed to validate the backend’s usability by MPs (
All included physicians worked with computers in their daily practice but did not have profound IT knowledge. A short feedback session was held after each task, allowing the physician to suggest improvements or to ask follow-up questions. If there were breaks or difficulties in the operating flow, the specific underlying reason was explored (
Again, all change requests and issues of the 5 pretest runs were discussed in the second feedback round within the development team, and improvement of the backend beta version was initiated. The required time spans for the given tasks in the final backend version were obtained again for 10 retest users to reevaluate the UX optimization success (
UX optimization and evaluation process. UX: user experience.
An in-screen frontend simulation provides the backend user with a preview of modifications made. This UX optimization tool provides a user-friendly visual interface and feedback mechanism between the back- and frontends (
An onboarding system was established to facilitate it for first-time users to get started using the backend. The user is guided step by step through the individual functions and necessary action paths by means of pop-up explanatory information.
All investigations with human participants were carried out with the consent of the Ethics Committee of the University of Duisburg-Essen (18-8142-BO), in accordance with national laws and in accordance with the tenets of the Declaration of Helsinki of 1975 (in the current, revised version).
In total, 1 female and 4 male physicians (mean age 39.2, SD 39.2, range 32-46 years) took part in the UX pretesting. All pretest participants were able to complete the tasks in the given time frame. On average, pretest users needed 3.33 (SD 1.05) minutes for the first, 4.04 (SD 0.40) minutes for the second, 7.14 (SD 1.34) minutes for the third, and 5.19 (SD 1.25) minutes for the fourth test flow for completion. The basic beta backend concept with the respective layout, menu navigation, wording, design, and color scheme was understandable to all participants. The handling was intuitive to learn with a few exceptions. If workflow interruptions occurred, the causes were clearly identified in the feedback rounds. There were some minor errors in the backend during the test rounds. Time saving was shown to be the top priority for backend usage (
In the retest, 10 physicians needed on average 2.11 (SD 0.42) minutes for the first, 3.23 (SD 0.36) minutes for the second, 5.14 (SD 0.46) minutes for the third, and 4.33 (SD 0.59) minutes for the fourth test flow completion (
Test flow completion time. On average, 5.03 (summarized SD 1.07) minutes for the test run. In the retest, on average, 3.50 (summarized SD 0.45) minutes for the test run.
InfectioApp provides a compact guideline on the appropriate use of antibiotics and other anti-infective agents for the treatment of human infectious diseases. The guideline addresses physicians as well as other MPs and was created by the Saarland InfectioSaar Network in collaboration with the Antibiotic Stewardship Team at Saarland University Medical Center, Homburg, southwest Germany.
In addition to diagnostic and treatment recommendations, InfectioApp provides background information regarding important pathogens and clinical symptoms, and detailed guidance on appropriate dosing of anti-infective drugs in patients with renal or hepatic insufficiency. References to further literature are provided within the guideline. InfectioApp’s content corresponds to approximately 200 DIN A4 pages and is updated regularly (
Data content management system–based apps in orthopedics, infectiology, and plastic and reconstructive surgery.
The Fachklinik Hornheide App was specifically developed for a plastic, reconstructive, and aesthetic surgery department. Targeting patients, this app provides an overview of surgical procedures, indications, pre- and postoperative data, and general information about the hospital and the respective hospitalization.
To assess the specific needs of the patients, a survey about wishes and requirements was performed in the outpatient clinic before creation of the app (
The backend was used to generate 3 different therapy plans for conservative or surgical therapy of forefoot and hindfoot disorders, based on the latest related medical literature and national guidelines. Special efforts have been made to ensure that communication of information is concise, clear, and easy to understand. With the cooperation of physiotherapists, a simple training program was created, which can be carried out without special equipment. A total of 15 exercises were made available to patients via the app. A special focus in this training circle was placed on early functional mobilization and stretching exercises (
Our study illustrates that backend integration offers great potential as an effective tool for app development in the mHealth sector. Specifically, backend operability for physicians and the implementation of end user–operable backends tend to be the key functions. The basic backend concept turned out to be clear to all test users, and its handling was intuitive to learn. Besides ease of usage, time saving was another key factor for backend usage. By establishing a practicable UX evaluation test protocol for the first time, we provide a basis for well-structured future software UX evaluation. Reasons for workflow interruptions in backend use have been identified and eliminated in the UX evaluation test. Finally, the developed backend was tested for its success on the basis of several pilot apps.
For now, the rollout of digital health apps has not led to the intended disruption of widespread smartphone implementation in the German health care sector. The reasons for limited availability of apps on prescription could not yet be determined, but opinions have been expressed that neglecting MPs in the app development process is one of the main reasons [
The benefits of backend usage are not new and represent an established method for processing large data sets in a software architecture. In the medical field, there have been some innovative approaches that have taken advantage of the high scalability and flexibility of backends [
It is debatable whether using “off-the-shelf” apps is at all feasible. In this context, the need remains for customized software that addresses individual use cases rather than one-size-fits-all solutions [
Backend-based stand-alone apps with individual functions, a unique app logo, and the implementation of individual corporate designs might be developed more efficiently than the alternative of “starting from scratch” with every app. An even simpler alternative could be a contentless home app with predefined functions that communicate with the backend. This content could be adapted to the respective requirements via the backend and be transferred to the home app via QR codes or links, which could then personalize the app. Ensuring a high quality of the generated content remains challenging, and the establishment of a quality management system has to be mandatory.
This highly effective concept also allows focusing on small, financially less lucrative pathologies such as a hallux valgus—contrary to greater financial interests by established companies.
Usability is a quality attribute that measures the user’s interface handling. In software, usability is a necessary basic condition to survive [
In this context, the development and reevaluation process in a multidisciplinary team was proved to be crucial. It was value-adding to see how the different perspectives and foci of medical professionals, developers, and usability specialists on software usability diverged and finally merged into one vision. In conclusion, the importance of the discourse among individual perspectives must be emphasized.
This study has some limitations. The backend’s usability optimization process was evaluated as a practical approach. However, it is based on principles that have already been established decades ago in other fields. Nevertheless, these aspects are relatively new in the health sector [
The advantages of the study are that a practicable procedure, based on existing theoretical approaches, of backend and UX optimization is documented and made available for other app developers and developing teams. Furthermore, the principle and functionality of backend integration in medical apps is described. Evidence regarding the usability and benefits of backends in combination with health apps is rudimentary. Thus, the study provides valuable insights into the participation of medical staff and the value of backends in the development of health apps.
Important cornerstones of digital technologies are flexibility and adaptability. An increase in the knowledge and progress in the field of medicine is rapid, so mHealth apps must also be able to transfer this pace into everyday clinical practice. With the introduction of every new innovative technology, usability plays a decisive role in whether the technology is ultimately used and can establish itself. Backend structures could be the next compelling step in the evolution of promising mHealth solutions, both technically and economically, as these enable the practical involvement of health care professionals in the app functionality and content configuration. However, comparative studies are required to gain funded evidence regarding the systems’ effects on treatment progress in comparison with established nondigital therapy paths to reach a final scientific conclusion.
Backend operability for physicians offers great potential as an effective tool for the development of apps in the mHealth sector. A sophisticated and time-saving UX emerged as the top priority for medical software usage. Basic interventions are sufficient for adequate UX optimization. UX evaluation of practicable, well-structured software is possible based on the UX evaluation test protocol.
User Experience Evaluation Test.
User Experience Evaluation Test (backend beta version).
data content management system
mobile health
medical professional
user experience
We acknowledge the support of the publication costs by the Open Access Publication Fund of the University of Bielefeld and the German Research Foundation (DFG).
The data sets generated and analyzed during the current study are included in this published article and its supplementary information files or available from the corresponding author on reasonable request.
FD and SB are active in Mediploy GmbH and in the development process of all mentioned apps.