IT Innovation Contest

A team-based contest for creative IT solutions

The Pap App

Proposal Status: 

Project Description:  The American Cancer Society (ACS), American Society for Colposcopy and Cervical Pathology (ASCCP), American Society for Clinical Pathology (ASCP), and the U.S. Preventive Services Task Force (USPSTF) have recently released revised guidelines for cervical cancer screening that downplay the role for annual cytology screening, long a mainstay of cervical cancer prevention. While the two sets of guidelines — one from a joint ACS/ASCCP/ASCP expert panel and the other from the USPSTF — differ in certain details, they are generally similar and likely to cause confusion and concern among women accustomed to older recommendations for more frequent screening. As always, the best course of management is for women, empowered with knowledge of the guidelines and well-informed of the their own test results, to engage in constructive dialog with their providers about individualized management. Factors such as age, results of recent screening tests, and medical history all enter into management decisions. The Pap App will provide a mobile (iOS) database for women to keep track of their test results and see what the guidelines recommend based on their individual results, while encouraging women to engage in dialog with their providers about the best approach.

 

Project Deliverable:  The Pap App will be a FileMaker-based application that can be loaded onto an iPhone, iPod, or iPad. It will run on top of the free “FileMaker Go 12” iOS database app (available in the Apple App Store), into which it will simply be loaded as a file, via direct download through mobile Safari (hosting site TBD) or through iTunes. On first opening the Pap App, a woman will enter her date of birth and relevant medical history. A “read-me” screen will provide an overview of the app’s purpose, general information about HPV and cervical cancer, and a disclaimer that the Pap App is not a substitute for professional care provided by a qualified clinician, but rather is intended to help the patient understand how the current guidelines apply to her. After each visit at which a cervical cancer screening test (e.g., cytology or HPV testing) is performed, the woman will be able to enter her results and, with a tap, bring up a screen to see what the guidelines would recommend for follow-up testing intervals and approach. Wherever the two sets of guidelines differ, this will be indicated.

 

Impact:  The Pap App will leverage UCSF’s long-standing role at the forefront of HPV and cervical cancer research and contribute toward the university’s mission to improve health care outcomes. While cytology screening has markedly reduced mortality from cervical cancer in the U.S. and elsewhere, changes in guidelines for cancer screening are often cause for confusion and stress, potentially leading to negotiation between patient and provider that results in overscreening or inappropriate management. By empowering women to understand how the new guidelines apply to their individual histories, it is hoped that the Pap App will contribute toward the guidelines’ goal of “maximiz[ing] protection against cervical cancer while minimizing the potential harms associated with false-positive results and overtreatment” (Saslow D, et al. Am J Clin Pathol 2012;137:516-42.).


References

Moyer VA. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2012;156:880-91.

Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. Am J Clin Pathol 2012;137:516-42.

 

Team Members:  

Mark Scott, MD, visionary, project coordination, and programming — will provide overall direction as well as database and user-interface design and programming. Dr. Scott is a FileMaker 12 Certified Developer and co-investigator on the “Natural History of HPV in Adolescents” study (NCI).

Anna-Barbara Moscicki, MD, subject matter expert — will provide expert consultation regarding the guidelines and algorithms, as well as critical feedback on the overall app design. Dr. Moscicki co-chaired the “Impact of HPV vaccination on future screening practices” working group of the ACS/ASCCP/ASCP expert panel and is principal investigator on the “Natural History of HPV in Adolescents” study.

Janet Jonte, NP, content creation — will provide consultation, from a provider’s perspective, regarding expression of the guidelines in patient-centric terms as well as critical feedback on the overall app design. Ms. Jonte has extensive experience providing gynecologic care to adolescent and adult populations and has examined and counseled patients in the “Natural History of HPV in Adolescents” study for the past 13 years.


Estimated Time Commitments:

Mark Scott: 115 hours (35 hrs departmental and 80 hrs independent, see attached letter of pre-approval)

Anna-Barbara Moscicki: 30 hours

Janet Jonte: 10 hours (departmental, see attached letter of pre-approval)


Comments

I like the idea, but a Filemaker-based solution may have very low usability, given that it requires users to (a) download an apparently-unrelated Filemaker app (i.e. Pap App won't be in the app store), and (b) use an infrequently-used iTunes-based sideloading mechanism (iOS no longer requires users to sync to a computer, so many users won't have iTunes set up). Could this be implemented as a traditional mobile app?

Great questions; thank you for those. Taking them out of order, we should indeed have mentioned other routes for adding a file to FileMaker Go, including emailing it or — perhaps most relevant and appropriate for distributing the Pap App — downloading it into FM Go directly from a web server through mobile Safari (http://help.filemaker.com/app/answers/detail/a_id/7754/~/transferring-fi... and http://www.vtc.com/products/QuickStartFileMakerGo/Installation/98180). We’ll update the proposal accordingly. Re the first point, while true that the FM Go 12 download will be a prerequisite, it’s not different from the familiar (if less common these days) scenario of downloading the free Adobe Reader before downloading a PDF. Much like websites that provide a link to Adobe’s download page next to their PDF download link, a link to the FileMaker Go page in the iTunes Store could be provided alongside the link to download the Pap App. (I just now downloaded FileMaker Go 12 to a new iPad and it took less than a minute.) Thus, we’d argue that the one-time FM Go download step is not likely to be a significant deterrent to adoption. As a bit of an aside, there was also a new method presented just last week at the annual FileMaker Developers’ Conference for creating a custom iOS home-screen “launch icon” that directly launches FM Go into a specific database (once the database is on the device, of course), much like opening a document directly from the desktop on a Mac or PC, vs. first launching FM Go and then navigating internally to the Pap App. This, too, helps contribute to a relatively seamless user experience. As for the last point, FileMaker was chosen due to the team’s expertise and years of experience with that development environment, thus marrying subject-matter and technical expertise. We’d propose that its rapid application development environment allows the development of robust, data-driven applications in a fraction of the time required to do so in a more conventional coding environment combining Objective C and SQLite. The development feature set is ideal for this sort of project and helps to ensure success within the 7-week project timeframe. Also, team members will be able to review beta versions of the Pap App on their iOS devices throughout the development cycle without the onus of creating the provisioning profiles that Apple requires for beta testers of traditional apps.

In general, apps that allow individuals to better participate in their health care should be promoted. Cervical cancer is indeed a major concern for women, and this project has the potential make a large impact. I share some of the concerns about using FileMaker Pro, however, I do agree that it is not a large burden if the installation instructions are simple and easy to follow. Two other concerns should at least be contemplated: (1) notification of updates to the app - how would this be handled? how would existing data migration occur with updates to the database? (2) if user data is resident on their device, would it survive a device reset and reinstall if iTunes was not used to create a backup?

Thanks, Enrique, for the questions. Regarding your first question, my proposed approach entails a “Check for Updates” button on the app’s main navigation screen. This would open a web viewer screen (i.e., right inside that app, not requiring a switch to Safari) to the app download page on which any recent-update notifications would be posted (with link). As this would all happen within the app, the process should be reasonably seamless. There are likely other feasible approaches and I welcome thoughts on this. (Arguably, the best approach to finding out about updates is one that requires no user volition, like Mac OS X’s Software Update or the third-party Sparkle mechanism; the iOS App Store doesn’t even provide a system quite so volition-free, requiring, instead, a periodic trip to the App Store to check for waiting updates.) Existing data migration will be handled by using a two-file schema, with user data held in one file, which is not overwritten in the update process, and all UI and logic components in a second, updatable file. (For initial download and install, the two files would be combined in a folder and zipped for single download.) Regarding a device reset and reinstall sans iTunes, iCloud Backup (as distinguished from iCloud’s “Documents and Data syncing,” the latter working only for “enabled” apps) backs up all apps' data and documents to iCloud.

At this point I think the technology is still secondary to the user experience design. What is the desired interaction with the intended user? How do we motive these women to participate and use the app? What sort of information is needed and how can the app make it easy and quick for the women to enter the information needed? Would embedding videos to explain each guideline make the app more engaging? The resulting design is what then should drive the technical delivery decisions.

Thanks, Jeffrey. I concur that superlative and engaging user-interface design is key (although that’s a bit like saying I like sunshine). Data entry in FileMaker Go uses familiar, touch-based input techniques, such as popovers for selecting values from a list and iOS-style date pickers. While the new screening algorithms are somewhat convoluted—necessitating some well-thought out, logical branching under the hood—the amount and scope of patient data needed is (generally) relatively minimal. One advantage of that fact is that I’m tentatively envisioning one app mode (not the only one) that would allow users to enter data freshly and not store it at all, just to increase the comfort factor for those users not comfortable with storing sensitive medical information on a mobile device (device-level password protection, app password protection, and “Find my iDevice” notwithstanding). At this early stage, I’m not convinced of this option, but I have inclinations in that direction. (The app’s “regular” mode, in contrast, would allow storing a record of cumulative screening results.) Mind you, for many women, these screening tests will now happen only every three years, so again, the volume of user information required is generally not great. I like the video idea and it is certainly feasible, either embedded (while minding file size, of course) or streaming over the internet. On the other hand, in many cases—e.g., a common recommendation of “the guidelines recommend that you should be screened again in three years; be sure to discuss the best personalized approach with your health care provider.”—links to authoritative lay information sources (e.g., ACS’s cancer.org and similar sites) might be more useful, if less engaging, than video. Either would use FileMaker’s embedded web viewer, a feature I fully envision supporting extensively. To their credit, FileMaker has bundled a robust feature set into the (now-free) FileMaker Go iOS app, including support for charts, web viewers, video and audio streaming, and so on. From a UI-standpoint, there are a lot of attractive options.

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