Using patient research to improve a mobile postoperative wound-monitoring experience

After patients leave the hospital, signs of a surgical-site infection can develop before their scheduled follow-up visit. WoundCheck was conceived as a way for patients to submit wound photographs and recovery information to their care team from home.

Our challenge was not simply to determine whether the technology worked. We needed to understand whether patients—including older adults, people unfamiliar with smartphones, and those recovering from major surgery—could use it successfully enough to provide clinically meaningful information.

Project Overview

My role
UX and usability research strategist contributor, co-investigator, and equal-contributing co-author

Organization
Marshfield Clinic Research Foundation, in collaboration with the University of Wisconsin Department of Surgery and Wisconsin Institute of Surgical Outcomes Research

Team
Surgeons, health services researchers, UX and usability researchers, community research advisors, software developers, and clinical reviewers

Methods

Community focus groups
Task-based usability testing
Direct observation and screen recording
Qualitative feedback
System Usability Scale
Clinical image-quality review
Iterative prototyping
Adult-learning principles
ISO 9241-11 and ISO 9241-12 usability standards

Participants
Nine vascular and general surgery patients, including patients with limited smartphone experience and patients assisted by caregivers

The Context & Challenge

A vulnerable gap in postoperative care

For many surgical patients, the period between hospital discharge and the first routine follow-up appointment lasts two to three weeks. Complications can emerge during this interval, but patients may have little formal communication with their care team.

Surgical-site infections are an important cause of hospital readmission. Patients may also struggle to recognize whether a wound is healing normally or requires clinical attention.

Mobile health presented an opportunity to create a more continuous connection between patients and clinicians. However, existing postoperative technologies had several limitations:

Many depended primarily on text or telephone communication and lacked visual wound information.
Some provided episodic rather than ongoing follow-up.
Provider review of submitted information was not always assured.
Previous telemedicine studies frequently excluded patients who lacked access to or familiarity with mobile technology.
Few applications had been rigorously evaluated with the people expected to use them during recovery.

This created a strategic question:

How might we enable patients to share clinically useful wound information from home without designing only for people who are already comfortable with mobile technology?

Project goals

The multidisciplinary team set out to:

Develop an image-based mobile experience through which patients could photograph their surgical wound and report recovery symptoms.
Determine whether postoperative patients could complete the experience effectively and efficiently.
Evaluate whether submitted photographs were useful for clinical decision-making.
Identify the interface and training changes needed to make the experience accessible to older adults and novice smartphone users.
Establish a stronger patient-centered foundation for future implementation of remote postoperative monitoring.

Research & Insights

Defining success beyond task completion

We used ISO 9241-11 to evaluate three dimensions of usability:

Effectiveness: Could patients complete the required tasks?
Efficiency: How much time and assistance did completion require?
Satisfaction: How did patients perceive the experience?

Because this was a healthcare product, task success alone was insufficient. A patient could believe they had completed the process correctly while still submitting an image that clinicians could not use.

The research therefore included a second layer of validation: three physicians independently assessed whether the submitted wound photographs were sufficient for diagnostic and treatment purposes.

Building community input into the design

Before formal patient testing, two focus groups were conducted with Community Advisors on Research Design and Strategies. These advisors represented varied racial, socioeconomic, educational, and technology backgrounds.

Their feedback helped the team evaluate:

The clarity and interpretation of application language
The readability and layout of screens
A sixth-grade reading-level target
The use of simple yes-or-no symptom questions
Image-capture instructions
Training materials for people unfamiliar with smartphones

This early input reinforced an important design principle: accessibility needed to be incorporated into both the interface and the learning experience.

Observing patients in context

Participants completed a realistic sequence of activities:

Wake and unlock the mobile device.
Open the application.
Photograph the surgical wound.
Review, accept, or retake the photograph.
Answer questions about symptoms and recovery.
Review their responses.
Submit the information.

Sessions were directly observed, audio-recorded, and mirrored to a research computer for screen recording. Researchers documented task completion, time, assistance, confusion, and errors.

Testing occurred in two rounds. Findings from the first round informed interface revisions that were evaluated in the second.

Key insight 1: The central interaction was also the greatest barrier

Taking a clinically useful wound photograph was the most difficult part of the experience.

Sixty-four percent of documented assistance involved image capture. Difficulties included:

Confusion between capture and cancel controls
Accidental cancellation
Difficulty positioning the device
Switching the direction of the camera
Inadequate lighting
Capturing only part of the wound
Physical difficulty seeing or reaching certain wound locations

The problem was not simply “mobile usability.” Successful image capture depended on an interaction among the interface, the patient’s physical condition, wound location, device familiarity, environment, and availability of caregiver assistance.

Key insight 2: Simple interactions reduced the learning burden

The symptom survey was easy for participants because it used a consistent series of yes-or-no questions.

One review screen, however, required scrolling—the only point in the experience where scrolling was necessary. This introduced a new interaction pattern and confused some participants.

Consistency was therefore more than a visual-design concern. It reduced the number of behaviors patients needed to learn while recovering from surgery.

Key insight 3: Confidence did not always equal clinical success

Participants generally rated their performance positively, including some whose photographs were not sufficient for clinical use.

This exposed a critical gap between:

Perceived success: “I completed the task.”
Technical success: “The application accepted my submission.”
Clinical success: “The photograph gives the care team the information it needs.”

For a healthcare experience, the interface must communicate what meaningful success looks like—not merely confirm that an action occurred.

Key insight 4: Training was part of the service, not an accessory

Novice smartphone users needed to learn how to operate the device before they could learn the application.

A uniform training program would either provide too little help for novice users or create unnecessary burden for experienced users. The team therefore treated training as a modular component of the overall service experience.

The training approach incorporated adult-learning principles, including:

Allowing the participant to set the pace
Combining demonstration with hands-on practice
Using repetition and multiple learning formats
Explaining why each task mattered
Providing positive reinforcement
Using teach-back to confirm understanding
Supplying reference materials for use after discharge

The Strategic Process

1. Connect the patient need to the clinical objective

The team framed the experience around a shared outcome: enabling patients to submit information that was both manageable for them to produce and useful for clinicians to evaluate.

This prevented the project from optimizing the patient interface independently of the clinical workflow.

2. Translate standards into practical design principles

ISO 9241-12 informed the interface strategy across clarity, discriminability, conciseness, consistency, detectability, legibility, and comprehensibility.

These principles were translated into tangible decisions:

Large, high-contrast controls
Tap-only responses
Minimal text entry
Consistent screen structures
Plain-language symptom questions
Review screens before submission
Visible submission confirmation
A linear path through the experience

3. Include perspectives beyond the product team

Community advisors reviewed language, interpretation, screen concepts, and training. Physicians assessed whether the resulting images supported clinical decision-making. Patients revealed the realities of using the experience while recovering from surgery.

These perspectives allowed the team to test not only whether the interface appeared usable, but whether the broader service could work across patient and clinical contexts.

4. Prototype, observe, revise, and retest

The first round of formal testing revealed two important interaction problems.

The camera screen placed the capture and cancel buttons close together, resulting in accidental cancellations. The revised design enlarged the capture area and separated it from the cancel control.

The response-review screen required scrolling. The revised experience divided the information across two screens and eliminated the unique scrolling interaction.

Participants in the second round completed the updated experience more efficiently and had less difficulty with the revised interactions.

5. Identify system-level requirements

Testing showed that interface improvements alone could not address every barrier. The emerging service strategy also needed to account for:

Tailored training for novice users
Caregiver participation for difficult-to-reach wounds
Clear standards for acceptable image quality
Accessibility for patients with limited dexterity or mobility
Device compatibility and technology access
Secure transmission and protection of health information
Integration with clinical review responsibilities

This broadened the work from application usability to service and implementation strategy.

The Outcome & Impact

Validated usability

The study produced several encouraging measures:

83.3/100 average System Usability Scale score, considered a good usability result
5 minutes average independent application-completion time
4.7 minutes average training time
55.6% of participants completed the full experience without assistance
81.8% of submitted photographs were considered clinically usable by a majority of physician reviewers
All nine participants believed they would benefit from the protocol
All nine said they could complete it daily after discharge with full instructions
Eight of nine would recommend it to a friend or family member following surgery

Actionable product improvements

Research led directly to interface changes:

The image-capture control was enlarged and separated from the cancel action.
A confusing scrolling review screen was replaced with two simpler screens.
Image review and retake opportunities were reinforced.
Training needs were differentiated according to device familiarity.
Additional support needs were identified for patients with difficult-to-photograph wounds.

Strategic value

The work demonstrated that an image-based postoperative monitoring experience could be acceptable to patients and capable of transmitting clinically meaningful information—even among people with limited mobile experience.

Equally important, it exposed the conditions required for responsible implementation:

Usability must be evaluated with representative patients, not only experienced technology users.
Clinical image quality must be validated independently of patient confidence.
Training and caregiver support must be designed as parts of the service.
Access to devices and platform compatibility must be considered to avoid worsening disparities.
Formal usability testing should occur before clinical deployment of novel patient-facing technology.

What the study did not claim

This formative study did not measure reductions in surgical-site infections, readmissions, cost, or revenue. Its impact was the validation of the experience concept, identification of implementation requirements, and reduction of product and clinical risk before broader testing.

What I Took Forward

This project reinforced a principle that continues to shape my design-strategy practice:

In healthcare, an experience succeeds only when the user’s action produces the intended clinical and operational result.

A patient-centered interface cannot be separated from training, physical ability, caregiver support, technology access, data security, and the clinical workflow on the other side of the screen.

The strategist’s role is to make those relationships visible—then help the team translate them into a coherent product and service experience.

Capabilities Demonstrated

Publication

Gunter R, Fernandes-Taylor S, Mahnke A, et al. “Evaluating Patient Usability of an Image-Based Mobile Health Platform for Postoperative Wound Monitoring.” JMIR mHealth and uHealth. 2016;4(3):e113. doi: 10.2196/mhealth.6023.

Designing a More Usable Path from Surgery to Home