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Mobile Health Design | Summer 2013 | Final Paper
PT|Home
Kim Paull
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Executive summary
Physical therapy (PT) is a low-cost intervention that may help patients avoid conditions requiring far
more expensive, invasive, and debilitating services. Because PT requires sustained investment from
the patient over longer periods of time, many fail to complete their course of therapy and relapse to
their original disease state or worsen their condition.
PT|Home, the app described in this paper, addresses common problems with unsupervised PT
treatment, including lack of adherence to the routine and poor performance of exercises. The app
has a user-defined reminder schedule that syncs with the user’s calendar and reminder system and
incorporates PT programs – defined either by the user or by the connected physical therapist – that
draw on a database of clinically valid exercises.
Background & Evidence-Based Guidelines
Physical therapy is a common intervention prescribed to patients who have experienced
musculoskeletal injuries, who are recovering from some types of surgery, or who have limited
mobility for other reasons. In addition to being relatively low-cost, PT is also a low-invasive
treatment and can forestall or speed the healing from more complicated and costly interventions,
such as surgery. For some patients, physical therapy is an alternative to surgery; for some, it is a
preventive measure before a condition worsens to a point requiring surgery. PT also helps patients
regain their full mobility following surgery.
Most low-complexity conditions requiring physical therapy can be partially or fully treated at home,
following initial and maintenance appointments with the therapist. At-home or unsupervised
treatments serve two roles: they minimize the cost and unnecessary disruption in the patient’s lives
by avoiding frequent trips to the therapist’s office and they reinforce the need to weave physical
therapy and its associated lifestyle changes into the patient’s routine life.
To maximize the benefit of physical therapy, patients must consistently invest in their treatment by
regularly performing exercises as prescribed by their therapist, either in the PT office or at home.
However, many patients fail to reap the full benefit of a PT routine because they have difficulty
adhering to the full course of treatment. Even if patients do finish the course of treatment, they
may not perform each exercise correctly, leaving them vulnerable to relapse, further injury, or
worsening conditions requiring intensive interventions.
Adherence is a particular problem for physical therapy and other interventions whose success is
most visible over time and that may involve a lifestyle change. One study of 300 physical therapists
in the Netherlands reported a complete adherence rate of only 35% while slightly over three-fourths
of patients completed some or all of the treatmenti.
Common reasons for non-adherence include poor relationship with the therapist, low knowledge
about the treatment and patient’s condition, negative attitude about the treatment, high time
commitment and high out of pocket cost of treatment (in the US, most PT sessions require a copay, at the minimum, for each visit).ii
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The chance of adherence, both in frequency and content, to a prescribed PT routine is greatly
improved by regular contact with a therapist, reminders, routines customized to the unique injury,
and explicit coaching through the exercisesiii,iv.
Target Audience & Personas
PT|Home, the physical therapy app discussed in this paper, is designed for patients recovering from
low-complexity injuries, surgery, or other impairment and for whom their physical therapist has
approved unsupervised treatment. The app is not appropriate for young children (under 10), frail
elders, those requiring specialized equipment, patients in the initial stages of surgical or traumatic
injury recovery, or those in need of monitored treatment.
For patients approved to recover outside of a PT office, the app is an ideal recovery partner. It
allows the patient and PT to connect through direct messaging, provides customization of the
routine by the PT and/or the patient, allows the physical therapist to monitor and encourage the
patient’s adherence, and includes camera and video features for more robust patient-provider
communication.
Personas:
1.) Rose, high school athlete recovering from ACL tear
Rose, a stand-out basketball player, recently suffered a torn ACL during a home game. The
injury required surgery, sidelining Rose for the remainder of the season. Eager to regain her
strength, fitness, and finesse before next fall, Rose is struggling to follow her surgeon’s
advice to incorporate physical therapy and gradual sport-specific maneuvers – into her
recovery program. Rose’s physical therapist senses her impatience and worries that Rose
won’t complete the program at the incremental pace she has prescribed, jumping too quickly
into pre-season training. She wishes she could connect in a more reliable way with the
effervescent, technology-adept teen rather than handing her the usual pamphlets to follow
between their weekly appointments. Rose also wants to use her new iPhone whenever
possible and was doesn’t want to carry around sweaty papers to the gym or around her
house like some of her friends who have also had injuries. She’s looking for something
cooler and more engaging.
Rose, after searching the app store in her (newly found) spare time, asks her therapist if they
can try PT|Home, which will allow the pair to match routines as Rose progresses, connect
the PT to Rose if either has questions, and do away with uninspiring paper-based exercises.
2.) George, 45-year-old office worker suffering from chronic low back pain
A proud government employee for twenty years, George has enjoyed his years of
intellectually challenging work and the calm, collegial atmosphere of his office. He is
thankful for the physical ease of his job, having watched his construction-worker father
forced into early retirement and disability payments after twenty-five years of pounding
work. However, George’s low back has irritated him from time to time and has recently
started to flare, sending acute throbs of pain down his legs. He has never been particularly
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active but is not overweight. Many of his co-workers – some in much poorer health than
him – have had the same problem, employing ice, pain killers, soft pillows, and sometimes
surgery to ease the affliction.
George thinks there might be an easier and more permanent way to fix his back, maybe
through physical therapy, but doesn’t have much experience in body movement or keeping
new, good habits. After visiting his primary care physician and a recommended physical
therapist, George knows he has a long road of daily stretches, exercises, and new habits
(including lunch time walks). He’s intimidated by the process and unsure how to keep up
the many new habits. He’s hoping there’s a way to cement his new routine without visiting
his PT every few days.
Indeed, George’s new PT recommends an app George can use on his new iPad that
connects him to the office, reminds him of routines with pictures and video, and is
updatable based on his progress.
3.) Marian, 55-year-old nurse recovering from shoulder strain
Marian, a vigorous emergency room nurse, recently strained her shoulder when she tried to
lift an overweight patient from a gurney onto a bed. Surrounded by practitioners and
imbued with deep medical knowledge, Marian is comfortable with the world of body
movement and physical therapy but also keeps an intense, and sometimes unpredictable,
work schedule. She is frequently on-call and spots other nurses who cannot make it to work.
She knows what she’ll need to do to recover from the injury – follow her physical therapists’
regimen closely and only gradually incorporate her shoulder into basic work routines – but
has never been the best “patient”. She lacks time, a consistent space, and the focus on her
own health to complete the full treatment. She’s hoping her PT, a colleague at the hospital,
can remind her to stay on track and make finishing a PT set almost automatic. If not, she
knows she’ll struggle to finish and may find herself with a chronic injury like many of her
peers.
Her physical therapist instead recommends PT|Home, an app he has tried with several of
his patient-colleagues and would like to bring to his general patient population. He believes it
will address many of her concerns and ensure she completes her program.
4.) Rob, 75-year-old retiree recovering from hip replacement surgery
After years of chronic pain from arthritis, Rob finally chose to get a hip replacement for his
right hip. He had the surgery several weeks ago, was discharged from the hospital and a subacute rehab facility, and is now ready to recover at home between regular appointments. He
is feeling strong, considering his circumstances, and both the surgeons and the rehabilitation
staff are confident that he will make a speedy recovery with several months of dedicated
physical therapy. His wife, Dawn, will help him remember and complete the routines his PT
prescribed, but wasn’t part of every discussion Rob had with the therapist. She also can’t
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remember exactly how the therapist performed the movements with Rob and both are
worried that they might impede his recovery if he does the movements the wrong way.
Rob and Dawn hope that the physical therapist will be available for regular contact outside of
the weekly visits – even for telemed and video visits, which they’ve use with other providers
since Dawn’s diabetes has worsened in the past few years. The PT office, they soon learn,
doesn’t support telemed yet but is experimenting with a new kind of patient connector – an
app called PT|Home.
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Competitive analysis
Survey of available apps
Searching “physical therapy” in the Apple app store yield 115 iPhone apps and 88 iPad apps (some
of which are the same, but reformatted for the respective medium). Approximately 70% of these
apps are provider-facing educational apps designed to teach current and future therapists about the
field or serve as “flash cards”. The remaining 30% are patient-facing apps that help patients track
their routines or list specific routines for a given conditions.
Of these 30% -- the focus for our competitive analysis – approximately half are limited to low-back
pain and half are multi-purpose. Of the multi-purpose physical therapy apps, several have reminder
functions, connections with the health professional, video and pictures of workouts, and predictive
and prescriptive programs. Some are expensive ($30 or more), low cost (under $5) or free (though,
in some of these cases, the patient must be registered with the paid version at the physical therapist’s
office).
Many of the full-function PT apps comply with evidence-based guidelines such as patient activation
through customized routines, patient-question database (answers provided by anonymous experts
or, in some cases, by the PT), encouragement, tracking, and patient-activated reminder schedules.
The best apps, and most direct competitors to PT|Home, in this competitive analysis are described
in the following table. From the larger pool of patient-facing apps, these four apps were chosen
because they incorporate all or most of the features in PT|Home, were all highly reviewed, had a
desirable interface, and employed easy-to-understand visual demonstration.
Multi-Issue
Reminder
Function
Exercises: Pictures /
Video
Customizable
routines
✓Patient or
PT|Home
($3.99)
✓
✓
✓
provider access
via direct
messaging
iHab (Free)
✓
✓
✓
✓
PhysioAdvisor
($3.99)
✓
✓
✓
iREHAB Back
Pain (Free)
PTVideo ($2.99)
✓
✓
Video only (25 exercises)
Connect to
physical
therapist
✓ Can use
without
registering
✓Must register
with PT
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1.) iHab:
Reason chosen: Most complete competitor to PT|Home, most engaging interface, and
most clinically integrated with patient’s prescribed physical therapy routine.
2.) PhysioAdvisor Exercises
Reason chosen: Most complete at-home solution for multi-purpose PT routines (without a
provider connection). Easy-to-understand pictures and instructions, customizable routines,
user-selected exercises in the “where does it hurt?” section
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3.) iREHAB Back Pain
Reason chosen: Most comprehensive and user-focused app in the back-pain-only niche.
Very easy to customize for the user, to track progress, to rate pain, and create predictive
routines.
4.) PTVideo.TV Pain Therapy
Reason chosen: Clearest and most inviting depiction of routines, complete with closed
captioning, real instructor videos, and customizable routines. However, the portfolio of
videos is limited.
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Description of app design
PT|Home is the most complete home solution for physical therapy patients. It not only builds on,
but also combines, the offerings of currently-available apps (reminder service, customizable routines,
PT connection, detailed video and picture depictions of routines). It is the only app that offers both
video and picture depictions of routines, a priority for physical therapy wherein success depends on
correct and consistent performance of movements. It contains detailed on-screen descriptions of
the exercise, is available on iPhone or iPad (Phase II development may include Android as well).
Importantly, it can be used by a patient interested in independently tracking his or her own progress
or in collaboration with a therapist, who is then able to adjust routines as the patient progresses,
monitor progress through patient check-ins, and answer questions via text or video.
The app incorporates evidence-based adherence guidelines that emphasize consistent therapist
contact and ensuring that the patient’s unique injury is understood and reflected in the routines. Its
independent mode provides a solution for those in the PT maintenance phase or those who wish to
self-treat without provider assistance.
A key function of this app is its reliance on tested, approved, and clinically meaningful routines. Its
pre-programmed routines and individual moves will not only be verified by leading physical therapy
experts (in partnership with the American Physical Therapy Association), but will also be chosen
from detailed surveys of physical therapy practices. The app will prioritize routines commonly
prescribed for specific goals (pain management, low-back pain, joint replacement surgery recovery
etc.) and sort moves based on the frequency and endorsement of surveyed physical therapists. The
development team will also include one certified physical therapist to supervise the clinical aspect of
the build.
Each of the target personas would find PT|Home useful for their particular situation or concerns.
Marian, the nurse with a shoulder strain, would benefit from the reminder service, the “playlist” of
exercises that encourages the automatic feeling of a PT routine, and the ability for her therapist to
monitor her progress and change the routines as needed – without requiring a new visit. Rob, the
retiree with a new hip, and his wife Dawn, will find PT|Home’s clear video depictions and direct
messaging capacity a relief after several weeks of hands-on rehabilitation. Rose is excited to
graduate from paper-based routines to an app she can control and carry, while still allowing her to
track her progress with her PT. Finally, George, the 45-year-old office worker with chronic back
pain, is encouraged by how the app is designed to help him make lifestyle changes (reminder service,
detailed descriptions, connection to his PT, and therapist-specific suggestions such as daily walk
breaks).
In addition to the patient-facing version of the app, developers will build a provider-facing patient
manager version, which will add a panel-tracking feature to the app itself. Patients will share
information with their therapist using a unique patient ID, similar to the iTunes “remote” app that
allows iPhones with a code for the user’s library to control music playback from their phone.
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Wireframes: Select Functionality of PT|Home
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Evaluation Plan
During the design of the app, the team will conduct evaluation sessions at critical points to ensure
users of the app find its functions useful, approachable, and seamless. Each of these sessions will
incorporate the key principles to encourage objectivity, uniformity, and effective learning. These
principles will include articulated goals for both the development team and the users, scripting of
questions, expressed limitation of the current test phase, and an outside (non-affiliated) note taker.
During testing, development team members (one will facilitate the session, one will provide content
leadership) will use these scripted questions to prompt testers for reactions before, during and after
their experience.
Testers and evaluators will be assigned roles – patient (novice, advanced), therapist, etc. based on
their actual expertise. Within each patient category, testers may be assigned personas (Rose, George,
Rob, Marian). Because of these constraints and need to cover a specific set of use cases,
demographic and personal history for each evaluator will be collected and noted in the final
compiled notes from each session.
These final compiled notes will include all positive and negative feedback as well as informative
descriptive comments that may be value-neutral. Notes will include summarized “action items” in
the beginning and an executive summary of key take-aways. Finally, at each stage, the facilitator and
development lead will prescribe a plan to incorporate the session feedback, prioritizing requests,
complaints, praise, and descriptive evaluations.
Evaluation Stages
1. Wireframe drafts: Our first evaluation will be a presentation of our wireframes to physical
therapists and a group of hand-selected patients (advanced users and one or two new users).
The goal of this initial evaluation is to ensure that the team’s vision matches, in the most
rough format, the likely way therapists and patients will use the app. In other words, before
we build, are we missing a major connection, function, or step that on-the-ground experts
will spot?
2. Simple routine “playlist”: Following the wireframe round, the second evaluation will test a
basic function: how well a new user can follow the on-screen pre-programmed routine
playlist. Are the pictures and video clear, engaging and clinically accurate? Do they cover the
correct details without overloading the patient with information? Can patients navigate
through the routine as needed? This round will also include a review of the reminder
function and self-tracking note feature.
3. Customizable routines: Once the team understands how patients and therapist prefer to
view routines, we will test the customizable routine feature, which allows both user groups
to create PT programs, similar to making a playlist in iTunes. Can users navigate easily in the
app to select routines from a variety of categories? Can they save and later access their
routines easily? Are there any bugs that cause the routines to play back imperfectly?
4. PT Connection: Finally, the team will test the most complicated feature of the app: the
connection to the patient’s physical therapist. We will ensure that the unique patient
identifier that the users will share is recognized by the system, that the patient can turn on
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and off the sharing of specific information, that the therapists can view information the
patient intends to share, and that both user groups can modify routines as necessary and can
respond to and send questions as intended.
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Development Plan
Before and between the evaluation sessions, the development team will code and build the app in an
iterative, exploratory yet quality-rigorous manner. The development, marketing, and design team
will collaborate on the initial wireframes that will guide the technical coding of the app. Following
approved wireframes, the development team will build the app according to the evaluation plan
phases (basic functions first; complex functions last). Within each step, the team will test amongst
itself and with non-technical user the reliability of the software (check every button on every screen,
ensure that different screens and functions work together as intended).
As mentioned above, the development team will include at least one licensed physical therapist to
monitor the clinical build of the app and ensure proper safety precautions/notifications are
incorporated.
Timeline
We expect the timeline for full development to be 4-6 months. The timeline takes into account the
provider survey and clinical verification of the routines as well as relationship building with provider
partners (American Physical Therapy Association, national conferences) and securing servers.
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Budget Item
Developers (staff)
Server and hosting
Design Software
Designer
Physical therapist,
consultant
Evaluation sessions
iTunes connect account
Marketing
Legal and
Administrative
Total
Notes
Writing app, writing server code (patient-facing
version and provider-facing patient manager)
Caching and storing PT-to-patient information
3dMax Design (mid-range app software)
3 weeks of work, spread over development period
5 days of work, spread over development period
4 sessions; food, drink, space, participation incentives
Standard fee
Office-based visits, conference fees and flights,
advertisements on APTA.org
Company charter documents, accounting and legal
counsel
Cost
$30,000
$10,000
$200
$18,000
$2,000
$800
$99
$5,000
$4,000
$70,099
The key cost-driver for this app is its ability to synch with the PT office, which requires data
exchange and caching through a server. Stand-alone apps without data transfer do not require this
extra step and do not allow different users to send and receive information. Such apps merely store
static user content.
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Marketing plan
The marketing plan for PT|Home will focus on two primary channels, reflecting its dual customer
base: patients and providers.
For patients, the main awareness channel will be through their PTs and, for more advanced users,
through the app store. The marketing team will prioritize excellent logo, graphics, user reviews, and
app store placement. The team will optimize app search terms including “physical therapy”, “back
pain”, “chronic pain”, “injury recovery”, and “stretching”. The plan will also include a 30-day free
trial during the opening months of sale and a 15-day free trial thereafter.
Though the main target audience for this app is patients, providers are key disseminators and
product referrers. As is true for many clinically-focused and clinically-integrated apps, provider
recommendations are critical. In order to engage providers and highlight the app’s use, the provider
branch of the marketing plan will focus on securing visible spots at PT conferences and clinical app
shows and advertising and partnering with the American Physical Therapy Association.
Price Structure:
The take advantage of the dual customer base and their different pricing needs, the app will be
offered with a 15-day free trail for patient users (one-time cost following trial of $3.99) and a onetime cost of $500 for a PT practice (unlimited confirmed-affiliated PTs can use one license; upgrades
fee is $150/year). For providers, the per-patient fee falls with each new enrollee and patients that
have independently registered or downloaded the app can join a practice’s patient panel at no extra
cost.
Limitations
Because this app targets patients but is channeled through providers, patient-awareness is a
vulnerability. The team, through its marketing and pricing plan described above, aims to limit this
weakness while preserving the focus on clinical accuracy and integration.
The app may also benefit from a phased-function introduction, prioritizing the user-created routines
and pre-programmed routine “playlists” above connection to the PT. The development plan, as
currently envisioned, is possible and ambitious. Should there be slow-downs, splitting the two
modes is a possibility to ensure a timely and quality-controlled roll-out.
Finally, the market supports several apps (including iHab) that are functionally similar. Though not
necessarily saturated, the competitors are well-developed and have dominate the customer channels.
These apps will either highlight our app’s relative weaknesses or generate positive competition,
driving our team to emphasize its niche (dual-mode, patient and provider-facing customizable
physical therapy playlists).
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References
Evidence-Based Guidelines
Geelen RJGM, Soons PHGM. Rehabilitation: an 'everyday' motivation model. Patient Educ
Couns 1996;28:69-77.
Jin J, Sklar GE, V. Min Sen Oh V, Chuen Li S. Factors affecting therapeutic compliance: A
review from the patient's perspective. Ther Clin Risk Manag 2008;4:269-86
Sluijs EM, Kok GJ, van der Zee J. Correlates of exercise compliance in physical therapy. Phys
Ther. 1993;73:771–82. [PubMed]
Von Korff M, Gruman J, Schaefer J, et al. Collaborative management of chronic illness. Ann
Intern Med1997;127:1097-102
App Development Costs:
Laurvey, Larry, Propelics.com, “iPad App Development Cost – A Breakdown”, Dec. 19, 2011
http://www.propelics.com/ipad-app-development-cost-a-breakdown/
Padgaget.com, “The Cost of Building an iPad App”, Oct. 17, 2010
http://www.padgadget.com/2010/10/17/the-cost-of-building-an-ipad-app/
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About the author
Kim Paull is completing her Masters in Public Health (Health Services Management & Policy
concentration) at the Tufts School of Medicine. She is also the Director of Analytics at the Rhode
Island Office of the Health Insurance Commissioner where she empowers critical health policy
decisions with data. Kim lives in Jamaica Plain with her wife and, when not “doing data”, lives on
rowing, running, tea and U2.
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Sluijs EM, Kok GJ, van der Zee J. Correlates of exercise compliance in physical
therapy. Phys Ther. 1993;73:771–82. [PubMed]
i
ii
Jin J, Sklar GE, V. Min Sen Oh V, Chuen Li S. Factors affecting therapeutic compliance: A review from the patient's
perspective. Ther Clin Risk Manag 2008;4:269-86
iii
Geelen RJGM, Soons PHGM. Rehabilitation: an 'everyday' motivation model. Patient Educ
Couns 1996;28:69-77.
iv
Von Korff M, Gruman J, Schaefer J, et al. Collaborative management of chronic illness. Ann Intern
Med1997;127:1097-102