Usability and Feasibility of Smartphone Video Capabilities for Telehealth Care in the U.S. Military

Introduction

The two-way audio/visual capabilities on the latest generation of smartphones and other mobile devices offer new possibilities for the delivery of telehealth care. This technology can provide real-time synchronous remote communication between patients and providers that is similar to what is currently delivered via traditional video-teleconferencing systems. Smartphone two-way audio/visual technology is already undergoing evaluation and testing for a variety of healthcare uses such as emergency care ¹ and medical consultation. ^2,3 This technology also has the potential to be particularly advantageous for use in the military healthcare system, especially for service members (SMs) who are mobile or have limited access to care when they are stationed in remote or deployed locations. Some of the advantages of smartphones, or other modern mobile devices such as tablet PCs, are that they are inexpensive, flexible, and mobile and can be particularly useful in rural and underserved areas where clinical services are not readily available. ^4,5

The National Center for Telehealth and Technology, a Department of Defense organization that includes as part of its mission the evaluation of new technologies for use in telemental health, began evaluation of mobile technology for telemental healthcare by testing long distance smartphone video calls from Joint Base Lewis-McChord, located in Tacoma, WA, to American Samoa, South Korea, and Iraqi Kurdistan. ⁶ The preliminary results of the evaluation were positive: reliable connections were made and maintained, and call participants had favorable assessments of the use of smartphone technology for telemental healthcare. Although it is expected that current and future applications of this technology will help to expand care delivery and services, additional feasibility and usability testing is needed to examine the general telemental health capabilities of these devices.

The present evaluation applies a usability lab approach to test the basic functionality, features, operation, and preferences for this technology among U.S. military SMs. Specifically, we tested the Apple's (Cupertino, CA) iPhone^® 4 smartphone device and FaceTime^® app to assess ease-of-use, adequacy of audio/visual capabilities, attitudes about use in healthcare settings, and whether the handheld device is ergonomically adequate for synchronous telemental healthcare use. It should be noted that when the study was initiated, only the Apple iPhone 4 featured the self-facing camera function that is necessary for adequate two-way audio/visual sessions. The study protocol was approved by our Institutional Review Board.

Subjects and Methods

Seven SM volunteers were recruited at the Pulmonary/Sleep Medicine Service clinic at a large military hospital located in the northwestern United States. Participants were given information about the study by the clinic nursing staff during clinic out-processing, and volunteers then met with a member of the research team who explained the study procedures, obtained informed consent, and conducted initial eligibility screening. Participants who reported physical conditions (e.g., color blindness, significant hearing loss, prosthesis, etc.) that would prevent normal use of the iPhone or presence of a pacemaker or other device sensitive to radio transmission were excluded from testing.

The evaluation consisted of a combination of observational, interview, and self-report survey data analyses. All testing was conducted with the Apple iPhone 4 with the FaceTime app. The iPhone 4 has a self-facing camera that supports 960×640 resolution. The Apple FaceTime app uses by default a picture-in-picture feature so that users can see themselves in a smaller window while viewing the remote person. Cellular hotspot devices (Sprint and Verizon) were used to provide Wi-Fi to 3G cellular connections.

In order to simulate a brief two-way video telemental health session between a patient and provider, volunteers were instructed to initiate a video call with the FaceTime app and complete an interview with a member of the research team (located at a remote location). The interview included a standard demographics survey and a survey (designed for this study) to collect information about the participants' experiences with technology. Each video session lasted for approximately 10 min. Participants conducted the testing individually and were observed by a member of the research team located in the same room. Following the video interview, participants completed a hands-on step-by-step usability test of the iPhone 4 and were further observed by a research staff member to collect additional usability information. Participants were then asked to provide their ratings on a series of questions about ease of use, comfort, and preferences for use of the technology (Table 1 gives the list of items). The usability measure was designed specifically for this study and was scored with a Likert-type format that asked respondents to indicate how much they agree or disagree with each statement on a 5-point scale (1=strongly disagree, 2=disagree, 3=neither agree nor disagree, 4=agree, 5=strongly agree). Participants were also asked to provide free-form written and verbal feedback during the testing session. Because we expected that not all participants would be familiar with the FaceTime app, we used the ubiquitous term “video chat” to describe the FaceTime application.

It should be noted that the video connections were difficult to establish at the testing space at the hospital because of cellular tower location (five of the seven testing sessions required several attempts to connect). The connection problems are reflected in the results described below. Although the quality of the cellular network connection was not ideal for evaluation, the connection problems provided useful data regarding such connection scenarios, and the feedback from the testing participants was helpful.

Results

Discussion and Conclusions

The results of this preliminary usability evaluation provide useful data regarding the usability and feasibility of two-way video capabilities of smartphones for use in the delivery of telemental healthcare. In particular, the present evaluation provides information about the ergonomics of handheld mobile devices with telehealth care in mind. The participants in our testing did not have any complaints about holding the smartphones during the video conversations. There were also no complaints about the size of the screen during the present evaluation. Our testing sessions, however, were short in duration, and it is possible that users might have complaints if sessions are longer. Stands used to hold the phone in an upright position are available on the market and may prove to be useful for longer sessions. Similar usability testing with longer video sessions and with mobile platforms that feature larger displays (i.e., tablet PCs) is warranted.

The present testing provides valuable data regarding the feasibility of using smartphones when network connectivity is less than optimal. Our testing scenario used hot-spot Wi-Fi-to-cellular connections that did not provide optimal connection speeds because of cellular tower location. There are many factors that can influence the quality of connection, including distance from cellular towers, weather, interference, volume of network traffic, and variation in network technology and cellular device. Reliance on cellular service might not be an optimal method for conducting two-way video-based telehealth sessions in many situations. When available, the use of Wi-Fi with fixed Internet connections may be more reliable in most settings, such as during combat deployments or for other remote locations. Network connectivity is an important issue that must be considered in any telemental health application that uses wireless devices. The probability of technology failure must be considered for any proposed clinical use, especially with high-risk patients. ⁸ Also, our current testing demonstrates how the quality of connection speeds can influence the user experience. Optimal delivery of telemental healthcare must ensure a simple and seamless user experience. Future testing of the technology that examines various connection scenarios and speeds is needed.

The present usability testing provides useful information that can guide future evaluation of this technology in military, federal, and civilian healthcare settings. Smartphones and other mobile technology platforms have potential uses for the entire gamut of synchronous telehealth applications: provider-to-patient consultation, the delivery of behavioral health treatments, therapeutic coaching, psychoeducation, medication management, and peer-to-peer consultation. Although use of Skype is approved for non-clinical counseling services, the use of smartphone apps such as Apple's FaceTime is not approved for synchronous clinical healthcare in the Department of Defense. This is based largely on device functionality, including screen size, resolution, and reliability of network connectivity, but also on security concerns for data at rest and in transmission. ⁹ Our recent article suggests that FaceTime may be utilized in a manner that is Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant, and there are other HIPAA-compliant solutions for the various smartphone platforms on the market. ⁹ Furthermore, the use of smartphones is popular among SMs while deployed and while at home. ⁷ We therefore recommend more rigorous evaluation and research of this technology not only to identify what works and what does not work, but to help to inform policy regarding its use in healthcare.