A mobile app implementing the international classification of functioning, disability and health rehabilitation set

In the twenty-first century the global demand for medical rehabilitation continues to increase, especially in low- and middle-income countries [1]. Functioning is the key indicator of successful rehabilitation [2, 3], so the functional evaluation tools shared by professionals are very important for rehabilitation practice. The International Classification of Functioning and Health (ICF) endorsed by the World Health Organization (WHO) in 2001 is considered the best unified framework for documenting and reporting functioning based on biological, psychological, and social perspectives [4‐7].The ICF conceives of functioning as a dynamic interaction between a person’s health, environmental factors and other personal factors. It has been recommended as a reference system for comparative evaluation and standardized reporting of rehabilitation interventions and their outcomes [8]. To facilitate the use of ICF, an International Classification of Functioning, Disability and Health Rehabilitation Set (ICF-RS) has been developed following a scientific process [9]. It can be used in the context of rehabilitation and disability to describe varying levels of functioning across different clinical populations and along the continuum of care [10]. Due to that the ICF-RS is only a list of 30 categories and lack of detailed operational items, a Chinese version of the assessment standards has been developed based on the established ICF linking rules [11, 12].

The Chinese assessment standards of the ICF-RS have been used across China, but data accumulation has led to some problems. For example, archiving the paper version takes up much storage space, easily leading to data being lost. There is also the not-insignificant cost of data entry. And the paper records can be difficult to share and compare between different institutions. With the rapid development of mobile health technology, mobile applications (apps) may be an effective tool for overcoming such difficulties. A mobile app could facilitate more frequent assessment, allow more objective data collection, save storage space, prevent data loss, and ensure high-speed data delivery [13‐15]. It can be used flexibly even without Internet access, making health information available without cite restriction [16]. Mobile health apps have been shown to improve efficiency and value while lowering costs [17]. At least 325,000 health, fitness and medical apps are now available in major app stores. About 78,000 new ones became available in 2017 alone. In that year there were 3.7 billion downloads of mobile health applications, an increase of 16% over 2016 [18]. Several mobile apps for the ICF have been reported [19‐21], but none is available yet for the ICF-RS.

The objective of this study, therefore, was to develop a mobile app based on the ICF-RS, test its utility and collect feedback for its further modification. The goal was an app suitable for frequently recording patients’ functional levels which could display functional changes graphically. It was designed to be suitable for tracking patients with different diseases in different medical institutions. At the same time, individual rehabilitation intervention plans can be made on the app based on the evaluation results. The app represents a real-world example of the application and promotion of the ICF-RS. The manuscript is organized as follows. The Methods section describes design and development steps of the app, the main technology used, and the setup of function modules. The Results section describes the developing process of the app; the results of the pilot test and the measures taken based on the feedback are also reported. The Discussion section describes the significance of app development and limitations of the study, followed by the conclusion.

The app was developed collaboratively by the Sun Yat-sen Memorial Hospital, Sun Yat-sen University and the Yunrun Big Data Limited Company. A core development group was set up, consisting of a senior professor and a postdoctoral fellow from the Sun Yat-sen Memorial Hospital, a product manager, a prototype designer, and a software development engineer from the company.

The app development procedure started in April 2018 and was completed in May 2019. The Agile development was used and the whole process was iterative. It included the developing steps of single evaluation version of ICF-RS, team evaluation version, rehabilitation interventions, and perfecting graphing function. Each iteration took about 8 weeks. The company delivered a revised version of the app at the end of each iteration, and the feedback was provided to the company for some adjustment as required. After passing internal environment test of the app, the technicians registered with the local Terminal to generate the unique key keystroke.jks in the production environment, and further reinforced configuration for the application package, including version number, version name, application package name and other relevant information. Open source code confusion with Android Studio to avoid the third party to decipher and steal source information. Package was released to a third-party application hosting platform and provided download links when it was generated and verified. At the same time, Git management tool was adopted to identify Tag for the specified version number and version update remarks, in order to perform standard management of app deployment. A mobile phone or a tablet computer running version 4.3 or later of the Android operating system is needed. The app was delivered to the end-user by providing website or the quick response code for download.

Five professionals were selected to give advice for trial use: three rehabilitation physicians, a physiotherapist and an occupational therapist. Twenty-five patients were evaluated in the pilot study using single evaluation and another five received team evaluation. The shortest evaluation time was 7 min, and the longest was 28 min. The average evaluation time was 17.4 min. The categorization of the participants and the evaluation times are shown in Table 4. The interface responded quickly and was considered user-friendly. Each module of the app worked as designed. No failures were recorded during the trial, and the data could be retrieved in both the app interface and the background system. The pilot study generated the following typical responses from the five participants.

All the feedback was organized and sent to the software development engineer for further modification and adjustment. The reminder was adjusted from 2 s to 5 s. The display of the telephone number and the ID card number were replaced by asterisks. The spelling errors for some categories were corrected. The admission and bed numbers were modified to allow any combination of letters and numbers. Jumping to the next category automatically during an evaluation was implemented.

The ICF is part of the WHO’s Rehabilitation 2030 initiative [26]. With today’s rapid data accumulation, combining mobile technology with rehabilitation seems to be a development direction for the future [27, 28]. Although the assessment forms based on the core sets and updated information about the ICF can easily be obtained from the WHO ICF website, no details about the operational items are provided. This study sought to provide them. The biggest difficulty during the development process was that the technicians and medical personnel did not understand each other’s expertise. A collaborative group and timely communication were, however, effective for ensuring the project’s progress. The pilot test results show that the development process was eventually successful and each module of the app worked normally. The average evaluation time of the ICF-RS using the app was similar to that with the paper version in a previous study. But when evaluation is complete, the mobile app handles assessment appointment, rehabilitation management and presenting the time trends graphically. That constitutes an example of effective combination of the ICF and networking technology.

Professionals and their patients are the two main users of the mobile health apps reported in previously-published studies. Some apps were developed to promote patients’ self-management, interaction between professionals and patients, disease screening or learning of disease knowledge with patients as the main users [29‐32]. Others were developed to cut costs and improve health outcomes with professionals as the main users [33‐35]. The app developed in this study belongs to the latter category. Its main advantage is its ability to promote online learning about the evaluation. Today the ICF’s assessment standards can only be promoted in China by organizing myriad training classes across the huge nation. Real familiarity can be promoted only by conducting clinical practice classes nationwide. Health care workers at the grassroots level and in remote rural areas do not have opportunities to learn about and master this technology. The mobile app may help to alleviate this problem [36], [37, 38]. All that required is access to the Internet. The standardized assessment rules can be mastered through on-site study and practice. Professionals unfamiliar with the ICF-RS can view the text, pictures or video guiding the evaluation process. The app also issues reminders for the next steps. In addition, incomplete functional evaluation data cannot be submitted unless it is to be supplemented. The final reports can be generated and checked by the raters at any time. These features can greatly promote the accuracy and completeness of the data tracking each patient.

A mobile app implementing the ICF-RS was developed successfully. Standardized assessment using the ICF-RS can be realized using the app. At the same time, individualized rehabilitation goals and plans can be formulated based on the evaluation results to achieve multi-professional collaboration in the rehabilitation process.