Using mobile applications in continuing medical

education
The Institute for the Study of Urological Diseases (ISUD) case study

Dimitris Spachos Dimitrios Hatzichristou Panagiotis Bamidis

Medical Scholl Medical School
Aristotle University of Thessaloniki Aristotle University of
Thessaloniki, Greece Thessaloniki
dspachos@gmail.com Thessaloniki, Greece
hatzichr@med.auth.gr
Medical School
Aristotle University of Thessaloniki
Thessaloniki, Greece
bamidis@med.auth.gr

Abstract——We describe the design, development and usage of
a mobile hybrid application (UROMobile), with a high usability
factor, in an interactive medical school with more than 120
attendees. UROMobile application offers support for several
learning activities, as well as program information, general
evaluation forms, profile information and many more. The
evaluation results shows that there is a successful case study on
how to use a mobile application in the education field.
Keywords—— mobile learning; m-learning; continuing
education; medical education; mobile technology
I. INTRODUCTION
The Institute for the Study of Urological Diseases (ISUD)
was founded in 2011 under the initiative of Scientists/
Academic members of the Aristotle University of Thessaloniki
(A.U.Th.). Among other activities, one of the main aims of the
organization is planning and implementing integrated
continuing education/lifelong learning programs for urologists,
physicians of related specialties, nurses, midwives,
physiotherapists and other health professionals [1]. Within the
context of continuing education, the Institute for the Study of
Urological Diseases has been organizing every year since 2008
the Interactive School of Urology (UROSchool) [2], for 4 days
at the end of spring, with at least 100 attendees every year, with
a maximum number of 120. The school targets at promoting
and improve theoretical education, critical thought,
communication between physician and patient, as well as
collaboration among medical specialties. The school is
officially recognized as an educational institution, for it is
integrated into the Continuing Education Program (EU-
ACME) of the European Board of Urology /UEMS based on a
credit-point system. The UROSchool is addressed exclusively
to urologists and contains several types of learning activities,
which are described in the next section.
II. TYPES OF LEARNING ACTIVITIES
The types of learning activities of the UROSchool are:
A. Workshops
Workshops deliver specialized knowledge upon issues
concerning every urologist. Each presentation lasts 10-15 min
and then follows a short discussion with the audience on
practical examples set by the tutors.
B. Interactive seminars
Interactive seminars focus on fully covering a nosological
entity. Thus, participants are offered the potential to have one
"final rehearsal" before incorporating and integrating the new
knowledge to their clinical practice.
C. Working groups/Virtual patients
Working groups are the most interactive part of
UROSchool. Students are divided in groups and discuss among
them, so as to exchange concerns and viewpoints. A case -in a
virtual patient form- is presented that has more than one
therapeutic option available. The use of virtual patients via a
web based application [3] provides each student the potential to
manage the case.
D. URO Swords
Duels have been diachronically the fight between two
opponents -the duelers- at a predetermined place and time, with
the presence of witnesses. Likewise, 2 urologists will 'duel' to
support 2 opposite positions. The process comprises structured
questions set by the 'Referee' of the duel. Every question
corresponds to one round. Following each round, the audience
votes in favour of the winner. The final winner is the one who
wins most rounds (the overall number of rounds is always an
odd number, so as to have a winner).
E. Surgical secrets
Surgical secrets probably compose the most difficult part
with regard to conveying skills and experience. They aim at
helping achieve the optimal surgical result and avoid
complications. All participants are called to expose their own
experience sharing secrets of their "surgical art", as well as
strategies for reducing the complication rate.
All types of learning activities have several questions,
available to the students at the end of each session, with a prize
given as a reward to the winner at the end of the school.

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 The students can also rate the tutors/speakers. The
following three questions were available to the students, in a 5-
point satisfaction scale from 1 to 5:
1. Was there any new knowledge?
2. Was the trainer well prepared?
3. Was this training experience useful?
The best speaker is also rewarded at the end of the school.
In first years of the UROSchool, the above activities were
supported and were accessible only through a web application
(which is described in section III). Each student had its own
laptop for accessing the application. While it's a classic case of
a computer supported learning environment, it also contains
collaborative actions and, thus, can be considered as a
computer supported collaborative learning environment
(CSCL) [4].
III. THE UROSCHOOL WEB APPLICATION
The web application developed on Drupal [5]. Drupal is a
free, open-source web development platform for online content
and user communities. It powers some of the busiest sites on
the web, and can be adapted to virtually any visual design.
Currently, Drupal runs over a million sites, including
WhiteHouse.gov, World Economic Forum, Stanford University
and many others [6].
Drupal was chosen mostly because it's reliable and easy to
extend (via modules), it's secure and robust, and contains a
strong permissioning system.
Numerous content types were created to represent the
different learning activities in the UROSchool. Modules were
developed as needed, for ratings, knowledge tests and the
results of them. At every moment, two dynamic pages with the
top ten students and tutors were available and presented live at
the UROSchool sessions in big screens and projectors,
reminding the contest to the trainees and motivate them to
participate. Both lists contained not only the names and scores
but also photos of the persons were in them.
The UROSchool program is organized in sessions and slots,
in an easy to find way. In every slot, at the bottom of its page,
are offered the knowledge questions and the rating widgets (in
a five star format). The UROSwords, have a slightly different
appearance, with the pictures of the two urologists in a central
place. Beneath them, there are one or more questions and
buttons for voting. After the voting, in the UROSword page,
the total results are displayed, with live update every few
seconds. The voting widget is closed during the UROSword
session and opens only after the end of it.
Virtual patients are represented also as slots and they are
running using the OpenLabyrinth1 application, which is open
sourced and free to use. The virtual patient cases are prepared
before the school by trained urologists. Every case is the
subject of discussion among the two main groups, so as to
exchange concerns and viewpoints. The final solution is given
by running the virtual patient in the main big screen of the
1 . http://openlabyrinth.ca/
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school. The virtual patient sessions are always the last sessions
in the day’’s schedule -usually 9-10.30 p.m- and the solutions
are always presented the next morning - usually 9-9.30 a.m.
The content administrator is able to create sessions, slots,
questions etc. as well as new school programs every year or so
without any programming knowledge. Questions are in
multiple choice format and free-text answers are not allowed.
Resources like PDFs, videos, presentations etc. are supported
for every session or slot, and they become available to all
school participants. The school’’s main title, description, dates
and other details are also configurable via a web interface. A
taxonomy reference system connects the entities of the system,
e.g. the sessions and their trainers/speakers are connected with
references between them –– they are not existing as plain
strings.
During the development, special care was given to the
usability and the user experience of the system: big buttons and
links, lots of white space, easy to understand labels, smooth,
readable screen fonts etc. Every person with basic internet
knowledge is able to use the application, without any extra
instructions or external help. A technical person is available
during the 4-day school, to help mostly with lost passwords or
usernames (although the system contains a reminder process
for lost passwords or usernames, by using just the email of the
registered user).
At the end of the school, at the 4th day, participants have to
complete an overall evaluation form, with questions for the
quality of the school, organization issues etc. The form is also
available in an electronic format, but the answers are
anonymous.
Although the web application works fine, there is a
drawback: the participants have to bring their own laptop, and
transferring it with them the during the whole 4-day school.
Most of the trainees own a smartphone and/or tablet and they
access the system from their devices. Despite the fact that
users are able to use it from their mobile web browsers, the
user interface is not optimized for small-screen devices,
making it difficult –– but not impossible- to use it. Thus, the
total user experience is poor. However, a 20%-30% preferred
to participate using smartphones or tablets (when the mobile
application wasn’’t available). Considering the above, the
development of a dedicated mobile app, that has the same
database as the web application, was inescapable.
IV. THE UROSCHOOL MOBILE
APPLICATION
The UROSchool mobile application (UROMobile),
designed to comply with at least the following requirements:
x Users must be able to login into it by using the same
credentials as the ISUD web site and the UROSchool
web application.
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 x The application must support all learning activities,
including rating, knowledge questions, the final
evaluation school form, the top students and tutors
etc.
Figure 1: The UROSCHOOL mobile application
x The application must be functional for every
UROSchool, thus, be able to read the school's data
dynamically, from the main database.
x Users must be able to use the application without any
external help.
x The application must be able to run even with lower
internet connection speed (e.g. GPRS instead of 3G
signal).
x The two main mobile platforms must be supported:
Apple's iOS and Google's Android operating systems.
There are many different kinds of technology that can be
classed as ‘‘mobile’’ [7]. The UROMobile is a personal
mobile/tablet application. The user logins with a single
username and a password, after he/she registers on the main
ISUD web site. After conversations with the project funder, we
decided not to give any registration options from portable
devices. The user registration form has a lot of mandatory
fields and, thus, the data entry from a smartphone or a tablet
it’’ll take a lot of time and effort. All users, immediately after
their school registration, received credentials (the email as their
username and a unique password) and a new account for each
user was activated, unless they already had an account from
previous years.
There are two main approaches when developing a mobile
application: hybrid vs native technologies [8] [9]. Hybrid
applications are the asiest to develop and cost effective, but
they have a performance penalty. Native applications are
written in each platform's native language (e.g. objective C for
iOS), they have great performance and native look and feel but
they are very expensive. With hybrid applications may be
difficult -if not impossible- to access some of the hardware
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components of the device, e.g. the camera or the accelerator
chip.
In the case of the UROMobile, we decided to go with the
hybrid approach, mainly for the following reasons, in order of
importance:
x The costs for the development of three native
applications were too high.
x The financier was receptive to a negligible
performance penalty.
x There was no requirement for use of hardware
components.
Hybrid applications run through a web view component
and, generally, can be assumed that follows the client-server
architecture.
The next step was the creation of a list of the necessary web
services. Hybrid applications use web services to exchange
data with the server, as well as handling the user
authentication. The services are developed as standard Drupal
modules, using the services [10] module as a base. JSON was
chosen over XML as the most appropriate data exchange
language between the mobile and the services endpoint. While
both JSON and XML are human readable formats, JSON's
parsing on the client side (that is the mobile application in our
case) is faster and uses fewer resources than its XML
counterpart; [11]. Another important reason is that JSON has
native support in JavaScript, which is the base scripting
language for hybrid applications. More than 40% of the total
development time dedicated to the web services creation and
testing.
A prototype of mobile application prepared using jQuery
mobile user interface library (jQuery Mobile UI) [12]. jQuery
mobile is a HTML5 based library. It contains a user interface
system designed to make responsive applications that are
accessible on smartphones and tablets. The prototype was
shown to the financier of the project and the desired corrections
indicated. Also, a new theme with fewer colors and flat
appearance adapted. This part of the project took up 30% of the
total development time.
Finally, the mobile application itself developed utilizing
HTML5, CSS3, JavaScript and the PhoneGap open source
framework [13]. All functions were tested on both iOS and
Android operating systems, in a variety of devices with
different screen sizes: from iPhone's retina (1136×640 pixels)
screen to the lowest HVGA (320×480 pixels) resolution. The
jQuery Mobile UI library, performed extremely well,
considering the large range of sizes and resolutions.
A unique feature that is worth mentioning, is the advanced
caching algorithm of the application. The HTML5 storage
engine used to deliver content from the local cache, instead of
the online database. The school program in JSON format was
78Kb (for the last year's UROSchool), including session titles,
timestamps, descriptions, author names etc. The amount of
78Kb may not sound big in today's internet speeds, but in
GPRS speeds can make a big difference. The algorithm checks
(with the use of a unique token) if the data in the cache are the
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latest. If not, loads them from the online database, using the
web service, while the user is on the main screen. When the
user navigates to the program section, it is already loaded and
displayed with no delay. Similar cache features are existing for
other data as well, e.g. the evaluation form, user pictures etc.
Another interesting function that added was the 'Quick poll'
utility. During the session, the speaker could ask a question to
the audience –– a question that can be answered with a definite
'Yes' or 'No'. Immediately, students could open the mobile
application, go to the quick poll utility and vote. The total
number of votes was displayed in the main, big screen in the
school's conference room. They are displayed in real time and
both as a percentage and a graphic. After the end of the voting,
the administrator resets the poll for the next possible question.
After a conversation with the financier, we decided to
distribute the application through the web, although it was
ready for submission to app stores. That is because we didn't
have enough time to beta test the application. In possible bugs,
the corrections had to pass through the app stores. In a 4-day
event, it was difficult to complete the entire submit-review-
approval process from both app stores. In agreement with the
financier, the application packaged as a web mobile app, and
distributed from:
http://www.imop.gr/mobile
In the beginning of the school, there was a 5 minute
session, informing users that they can visit the above address
through their mobile devices. A function developed, that was
able to detect if the client was visiting the ISUD web site
(http://www.imop.gr) from a mobile device or tablet and, then,
a pop-up message asked the user if he/she wants to continue on
the UROMobile (only once).
More than 80% of the trainees used the mobile application
from their smartphone or tablet. During the 4-day school minor
bugs were fixed, and the changes were immediately visible to
end users.
V. EVALUATION AND RESULTS
After the end of the UROSchool, a standard system
usability scale (SUS) [14] online evaluation form sent by email
to the trainees of the school and 23 (in a total of 100) users
responded. The SUS score is 78.125, which is positioning the
application -in terms of usability and learnability- between
'Good' and 'Excellent', in the adjectives SUS rating scale [15].
The sample size may be small, but it's totally reliable [16].
Overall, the application is quick and smooth, although not
as smooth as if it was native. It works fast, even within the
lowest available internet speed (GPRS). Its user interface fits
well in a variety of screen sizes and, thus, devices. It offers the
same functionality as the web application and allows anyone to
participate in the learning activities using only a smartphone or
a tablet.
Future steps include the distribution of the application
through the App Store and Google Play. The next version of
the application will support videos (all sessions are available
the next day as recordings) and functionality to recognize the
user by scanning a QR code with the device camera.
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The application exists within the larger space of the
UROSchool and its ecosystem. It can't work standalone,
because it's designed this way. However, it enhances the
overall learning experience. After the first year of use, it can be
considered as a crucial component for the UROSchool success.
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