Mobile app development: A new frontier

Mobile apps are playing an increasingly significant role in all industries and markets—and healthcare is no exception. Hospitals, freestanding facilities, and even some private practitioners are building and leveraging a wide range of these apps, from clinical decision support and case management options to those designed for such tasks as patient registration.

George Shih, MD, MSEE is associate professor and vice chairman, informatics, at Weill Cornell Medical College, New York City, N.Y. Addressing viewers of “Mobile Development of Consumer and Enterprise Apps in Healthcare,” a recent webinar sponsored by the Society for Imaging Informatics in Medicine (SIIM), Shih noted that while the healthcare segment may have been slow to adapt to the apps world at the outset, a desire among constituents to improve clinician education, patient care, workflows and operations has spurred development and deployment on the enterprise and consumer app fronts alike.

More widespread availability of app configuration and management tools is pushing the envelope as well, according to webinar presenters Charles T. Lau, MD, MBA, a cardiothoracic radiologist with the VA Palo Alto Health Care System in Palo Alto, Calif., and Ahmed H. El-Sherief, MD, a thoracic radiologist at West Los Angeles VA Medical Center, Los Angeles.

According to Shih, enterprise mobile apps—apps intended for mass distribution and internal use across an institution—can be created and distributed using a variety of development tools and programs. Apple’s iOS Developer Enterprise Program, which has been leveraged at Weill Cornell, falls into this category. The program is open only to entities with a Dun & Bradstreet (or D-U-N-S) number, at a fee of $299 per year. Program components encompass an iOS software developer kit, tools for testing apps on iOS devices, code-level technical support and ad-hoc distribution.

The BYOD connection

No matter their content, enterprise apps are delivered using enterprise mobile app deployment models—“bring your own device” (BYOD) and shared device. In a BYOD scenario, apps and other content, such as e-books, are downloaded on end-users’ personal smartphones or tablets. In a “shared device” model, multiple individuals utilize the same non-personal device, such as an iPad, to access a specific app. An iPad app used by patients to register at an outpatient-imaging site constitutes a good example of the latter, Shih said.

Weill-Cornell has had success with Apple Configurator, a tool designed to allow entities, including healthcare institutions, to mass-configure and deploy iPhone, iPad, and iPod Touch devices via a shared model. The tool includes workflows for preparing, supervising, and assigning devices.

• In addition to configuring multiple devices at the same time and updating devices to the latest version of iOS, the preparation workflow allows users to create and restore backups of settings and app data from one device to another device or devices, import apps into Apple Configurator and sync them to new devices, produce and install iOS configuration profiles with a built-in editor and enroll devices for remote management through a mobile device management (MDM) solution.
• The supervision workflow paves the way for organizing supervised devices into custom groups, automatically apply configurations to supervised devices (and re-apply them once a previous user’s data has been removed), import apps into Apple Configurator and sync them to supervised devices, define and apply common or sequential names to all devices and restrict supervised devices from syncing with other computers.
• The assignment workflow makes it possible to add users manually or auto-populate via Open Directory or Active Directory, perform check-in and check-out of devices to individual users, import and export documents between Mac computers and Apple Configurator, and more.

“One of the most important things that must be done with a shared model is to (harness) MDM to enforce a single-app mode, which means locking devices so they cannot be used for something other than their intended purpose,” Shih advised.  Again citing the example of a patient registration app deployed at an outpatient-imaging center, he explained that single-app mode enforced through MDM would prevent patients (or employees) from downloading any other app for use on the iPad.

MDM software is equally valuable in the BYOD realm; such solutions permit administrators to revoke or re-assign apps as needed, get alerts should unapproved apps be in use, and lock devices/re-set passwords as needed.

Consumer apps 101

While developing apps for internal use works well for Weill Cornell, others in the healthcare space have begun to focus on creating consumer apps available for download from “app stores.” Among them are Lau and Al-Sherief, who in addition to fulfilling their clinical duties are partners in RADIOLOGiQ, a provider of mobile apps geared towards all medical professionals who rely on imaging in their scope of practice.

RADIOLOGiQ currently offers about 12 clinical decision-support apps; examples include Lung Nodule Follow-up Guidelines (based on Fleischner Society recommendations) and Cardiac Imaging Planes: Step-by-Step, a text and video tutorial that covers the creation of standardized cardiac imaging planes on CT studies.

The company’s admittedly unusual business model calls for offering the apps free of charge—a strategy its principals believe increases “mindshare and market share”—and free of advertisements.

Lau and Al-Sherief said it behooves entities that want to develop their own consumer apps to follow their lead and consider handling the programming, coding, and graphic design in house, noting as their rationale the costs involved in outsourcing these tasks. App developers charge $50 to $350 per hour, with the average app requiring “hundreds” of hours of work and costing $50,000 to deliver.

“We also knew with this approach that we would have better control and could address bugs, user requests, and maintenance in the quickest way,” Lau said.

Evaluating operating systems

To simplify development and increase the potential for adoption, the clinicians took a methodical approach in determining which mobile operating system would power RADIOLOGiQ’s apps. They evaluated each candidate’s market share within the medical community, along with the ease of use afforded by associate development tools and the simplicity of the design-vetting process. The Apple iOS mobile operating system emerged as a winner.

Toward a similar end, Lau and Al-Sherief chose Apple’s Objective-C programming language instead of the vendor’s newer Swift offering. Objective-C is the primary programming language used when writing software for the iOS and OS X platforms, as well as the language employed by Apple and its developers to build iPhone and iPad apps.  Although Swift is gaining ground, Lau and Sherief observed, Objective-C is more established and far easier to learn than its counterpart.

Then, there was the question of mobile device support. The original apps introduced by the company were available only on iPhones. However, a growing tendency among “new-generation” physicians to bring iPads into the practice and leverage them to locate reference material spurred a decision to support these devices in updated versions of older apps and in new apps going forward.

Lessons learned

Experience has taught Lau and Al-Sherief several lessons about the technical nuts and bolts of app creation and maintenance, all of which they shared during the webinar. Topping the list:

• Ensure that the user interface is highly intuitive. For instance, in one app, a circular chart replaced a text box.
• Avoid coding until the user interface has been determined and “locked down.” If a mature user interface surfaces after coding work has concluded, headaches may ensue.
• Resist “stretching” the user interface on an iPhone app for use on an iPad app. Instead, tweak appropriately. Otherwise, iPad users’ experience will be compromised.
• Understand that iPhone apps may need to be modified when new versions of the device are introduced, as each version has a slightly different form factor. For instance, the clinicians said they are “re-building” apps to incorporate more content to accommodate the larger form factor of the next iPhone 7 model. This is an alternative to “stretching” content to fit a larger screen.
• Keep content below 100 megabytes. Otherwise, Apple will not allow it to be featured on and downloaded from the iTunes App Store.

“App development can be a major undertaking,” Al-Sherief concluded. “But it is a worthwhile one.”