Mobile phone apps for clinical decision support in pregnancy: a scoping review

All papers reporting on acceptability, feasibility, usability and/or satisfaction were generally positive, both with the mobile app being evaluated, and also with the care it was designed to support. This was demonstrated by direct questioning and evaluation tools, but also by increased patient engagement with, for example, compliance with self-monitoring [7, 21, 23]. Increased confidence of health providers, enhanced positive relationships and trust in the professionals and feelings of support and safety were also reported [18, 21, 22, 27]. Validation of data and monitoring readings were often a feature of the app, and this was recognised by clinicians as a valuable improvement in care [17, 24]. Additionally, apps appeared to help clinicians identify priorities and they recognized the potential for the system to be time saving. The automatic transfer of data to electronic central databases or health records was also identified as a useful mechanism which could save clinicians’ time as they could remotely review the data in advance of the patient’s hospital appointment [23, 28]. Alerts systems were utilised in some apps to remind patients of, for example, appointments, medication, and monitoring [21, 22], or alert remote clinicians who could respond with advice, either directly to the patient or their local care givers [21, 24].

Most medical app users were familiar with smart phones, and the benefit of portability was regarded as a great asset [22, 27]. Some users reported problems which were often related to the phone’s features, e.g. difficulties with entering data on a small mobile phone screen and the need for scrolling [17, 20]. Adaptation of features such as reducing the need for scrolling by having fewer data on each form, training and on-phone manuals were used to address these issues in later stages of app development [18, 24].

With the relative low cost of smartphones and convenience in terms of weight and size, along with the increasing connectivity to mobile networks, mobile apps appear to be accepted as an excellent opportunity for improving healthcare, particularly for those in low resource settings. One reason, proposed by a number of authors of the papers included in this review, is that less educated health care staff can be trained in providing front-line care using devices that are easy to use, with internal validation and warning alerts, with the added benefit of support from remote experts [24‐26].

The versatility and multi-functionality of smartphones appeared to be an important issue in the papers reviewed. As decision support tools, mobile apps can utilize statistical prediction models or decision trees and make recommendations for action based on input of individual risk factors and test results [16, 17, 23]. In addition to decision support, however, most apps (10/13) were also used for data collection, communication, or both. Other apps also incorporated Bluetooth internet connectivity with other devices: pulse-oximetry [20, 24]; blood glucose monitors [21, 23]; blood pressure monitors [22, 23]; digital weighing scales [22] and fetal Doppler devices [24]. One mobile app utilized the smartphone’s own camera for processing pictures used in the Congo Red Dot test to assess the presence of misfolded proteins in urine [19]. This test has been proposed as a possible diagnostic test for pre-eclampsia that could be particularly useful in low resource settings where more sophisticated laboratory facilities are unavailable.

Communication between patients and healthcare workers, or between healthcare workers and colleagues or other experts, was valued as an important element in the success of the projects in which the apps played a central role [17, 21, 27]. This appeared to be so whether the communication was carried out directly through the app, or simply by the user being able to communicate using the same device, i.e. mobile phone.

Data collection, validation, transfer and integration with other health records and research databases, and the ability to set alerts, as noted above, along with other integrated features of mobile phone technology, such as time stamping and Global Positioning System (GPS) tracking of phone location, were also noted as important and useful attributes because, for example, the time and place of the clinical visit could be recorded [17, 21, 23, 24, 28].

Delivering healthcare interventions through mobile technology also provided the opportunity to adapt programmes relatively easily to account for specific needs of the end-users. Accessibility was enhanced, e.g. picture and video instructions for illiterate users [24]. Language and cultural diversity issues were also relatively easily addressed and incorporated into different versions of the app [17, 21, 24].

The importance of user involvement in the development and evaluation of their app was emphasized in several papers [17, 20, 26, 28]. The authors noted that this was not only a key step in enhancing the acceptability and usability of the device/programme, but also a mechanism by which they could foster engagement by local stakeholders, community leaders and healthcare funders. This interaction was recognised as part of the pathway to ensure acceptability of the programme and to maximize its chances of being sustained.