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ScienceDirect
Procedia
Procedia
Procedia Computer
Computer Science
Science
Computer 14100
Science (2018)
(2018)
00 000–000
525–530
(2018) 000–000
www.elsevier.com/locate/procedia
www.elsevier.com/locate/procedia

The
The 2nd
2nd International
International Workshop
Workshop on
on Healthcare
Healthcare Interoperability
Interoperability and
and Pervasive
Pervasive Intelligent
Intelligent Systems
Systems
(HIPIS 2018)
(HIPIS 2018)
Step Towards Progressive Web Development in Obstetrics
a b c,∗ c c
Patrı́cia
Patrı́cia Loreto
Loretoa ,, Jorge
Jorge Braga
Bragab ,, Hugo
Hugo Peixoto
Peixotoc,∗,, José
José Machado
Machadoc ,, António
António Abelha
Abelhac
a University of Minho, Campus Gualtar, Braga 4710, Portugal
a University of Minho, Campus Gualtar, Braga 4710, Portugal
b Centro Hospitalar do Porto, Centro Materno Infantil, Porto 4099, Portugal
b Centro Hospitalar do Porto, Centro Materno Infantil, Porto 4099, Portugal
c Algoritmi Center,
c Algoritmi Center, University
University of
of Minho,
Minho, Campus
Campus Gualtar,
Gualtar, Braga
Braga 4710,
4710, Portugal
Portugal

Abstract
Abstract
The
The aim
aim ofof this
this paper
paper isis to
to develop
develop aa Personal
Personal Health
Health Record
Record (PHR)
(PHR) for
for the
the support
support of
of pregnant
pregnant women.
women. With
With this
this goal
goal in
in mind,
mind,
concepts
concepts such
such as
as PHR
PHR and and their
their importance
importance in in the
the obstetrics
obstetrics field
field are
are overviewed,
overviewed, asas well
well as
as mobile
mobile development
development strategies.
strategies. The
The
system
system waswas developed
developed withwith the
the support
support of
of aa medical
medical institution
institution and
and taking
taking into
into account
account what
what pregnant
pregnant women
women find
find useful.
useful. The
The
developed
developed appapp is
is aa Progressive
Progressive WebWeb App
App (PWA).
(PWA). This
This is
is aa recent
recent technology
technology that
that allows
allows the
the same
same app
app to
to work
work on
on most
most devices,
devices,
gives aa native
gives native feel
feel to
to it
it when
when using
using on
on mobile
mobile devices
devices and
and enables
enables offline
offline support.
support. Further
Further testing
testing is
is necessary
necessary to
to understand
understand the
the
impact
impact that
that this
this system
system maymay have
have in
in the
the engagement
engagement of of pregnant
pregnant women
women andand in
in birth
birth outcomes.
outcomes.
© 2018 The Authors. Published by Elsevier Ltd.
cc 2018

 2018 The
This
The Authors.
Authors. Published
is an open
Published by
by Elsevier
access article under
Elsevier Ltd.
Ltd.
the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0/)
This
This is
is an
an open
open access
access article
article under
under the
the CC
CC BY-NC-ND
BY-NC-ND license
license
Selection and peer-review under responsibility of the scientific (http://creativecommons.org/licenses/by-nc-nd/3.0/).
(http://creativecommons.org/licenses/by-nc-nd/3.0/).
committee of ICTH 2018.
Keywords: Personal
Keywords: Personal Health
Health Records,
Records, Obstetrics,
Obstetrics, Mobile
Mobile Development,
Development, Progressive
Progressive Web
Web Apps
Apps

1.
1. Introduction
Introduction

For
For the
the past
past years, with the
years, with the developments
developments in in the
the health
health information
information systems
systems field,
field, there
there has
has been
been anan increasing
increasing
interest in
interest in Personal
Personal Health
Health Records
Records [1].
[1]. A
A Personal
Personal Health
Health Record
Record (PHR)
(PHR) is is an
an electronic
electronic document
document that
that contains
contains
medical related
medical related information
information maintained
maintained by by the
the patient
patient himself
himself or or by
by aa family
family member.
member. It It provides
provides aa more
more detailed
detailed
summary of
summary of the
the patient’s
patient’s health
health history
history and
and turns
turns the
the patient
patient aa vital
vital stakeholder
stakeholder in in his
his own
own health
health management
management [2, [2, 3].
3].
PHRs have
PHRs have shown
shown toto improve
improve medical
medical decisions
decisions and
and therefore
therefore the
the services
services delivered
delivered by
by health
health professionals,
professionals, while
while
also reducing
also reducing their
their cost
cost [2,
[2, 3].
3]. Most
Most PHRs
PHRs provide
provide ways
ways of
of recording
recording clinical
clinical values,
values, as
as well
well asas other
other features,
features, such
such as
as
alarming the
alarming the patient
patient when
when abnormal
abnormal values
values are
are detected,
detected, giving
giving personalized
personalized information
information oror displaying
displaying appointments
appointments
[1, 4].
[1, 4]. Although
Although PHRs
PHRs have
have proven
proven their
their value
value in
in improving
improving healthcare
healthcare services,
services, there
there are
are still
still barriers
barriers to
to aa more
more wide
wide
adoption. One
adoption. One ofof the
the main
main challenges
challenges isis usability
usability and
and availability,
availability, since
since it
it is
is difficult
difficult to
to develop
develop aa system
system that
that can
can be
be
used by
used by all
all patients
patients nono matter
matter their
their age,
age, medical
medical condition,
condition, economic
economic status
status or
or technologies
technologies they
they use
use [3,
[3, 4,
4, 5].
5].

∗ Corresponding
∗ Corresponding author.
author. Tel.: +351 253
Tel.: +351 253 604
604 430
430 ;; fax: +351 253
fax: +351 253 604
604 471.
471.
E-mail
E-mail address:
address: [email protected]
[email protected]

1877-0509 
1877-0509 cc 2018
 2018 The
The Authors.
Authors. Published
Published by
by Elsevier
Elsevier Ltd.
Ltd.
1877-0509
This is
is an © 2018
an open
open The
access Authors.
article under Published
the CC by Elsevier
CC BY-NC-ND
BY-NC-ND Ltd.
license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
This access article under the
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
license (https://creativecommons.org/licenses/by-nc-nd/4.0/)
Selection and peer-review under responsibility of the scientific committee of ICTH 2018.
10.1016/j.procs.2018.10.131
526 Patrícia Loreto et al. / Procedia Computer Science 141 (2018) 525–530
2 Patrı́cia Loreto / Procedia Computer Science 00 (2018) 000–000

PHRs can be desktop-based, Internet-based or mobile [3]. However, given the previously presented barriers to
PHRs adoption, it would be of great interest to find a solution that reaches as many people as possible. To do this, it is
necessary to develop a system that can adapt itself to work properly in as many devices as possible.
In this paper a PHR for pregnant women is proposed. This system will be developed using the Progressive Web
App (PWA) methodology. Given this, in the next section a state-of-the-art overview of PHRs for the monitoring of
pregnant women and of the current mobile development strategies is presented. Then, the PWA methodology and its
main characteristics and advantages are explained. Finally, the developed PHR is presented and discussed.

2. State of the Art

2.1. PHRs for the monitoring of pregnant women

One of the areas where PHRs have shown to be a relevant tool for the monitoring of health indicators is the
Obstetrics field. PHRs are specially important in the monitoring of pregnant women, since pregnancy is a delicate
medical condition that needs extensive monitoring and where detecting problems in time is crucial [6, 7, 8]. PHRs
may save the woman’s medical history and other parameters, such as weight or blood pressure, making it possible for
caregivers to access these parameters in case of emergency [6]. However, PHRs can have other features like giving
information about the fetus and the changes in the woman’s body and a calendar for appointments [6, 9]. If the PHR
is connected to the institution that provides care to the pregnant woman, other advantages arise. Decision Support
Systems (DSS) help health professionals in the decision-making process and PHRs could be a way of providing more
information and more quality information to DSS, which may improve results [10, 11].
Bachiri, Idri, Aléman & Toval (2016) conducted a Systematic Literature Review to analyze the features of mobile
PHRs for pregnancy monitoring. 33 PHRs were analyzed and all of them estimated the due date, making this the only
feature present in all PHRs. The second most frequent functionality was the monitoring of haelth indicators, such as
weight or waist measurements. As for other features, 94% of the analyzed applications displayed information related
to the pregnancy state and 87% had a countdown until the due date or a progress bar [12].
To examine the impact that a mobile health application may have in birth outcomes and user engagement, Bush
et al. (2017) developed a study with two groups of pregnant women: one that used a mobile application provided by
them and one that did not. The group that used the application was small compared to the other group, not making
it possible to generalize the conclusions, but the use of the application was associated with a small increase in the
attendance of prenatal visits in the 6 months previous to birth and a lower incidence of low-birth weight newborns [8].

2.2. Mobile Development Strategies

According to the 2016 edition of the Statistical Yearbook from the United Nations, in 2015, there were 110 cellular
mobile telephone subscriptions per 100 inhabitants in Portugal [13]. A report from the Portuguese National Institute of
Statistics (Instituto Nacional de Estatı́stica) from the same year, found that 75% of families have access to the Internet
at home, 70% of the people between 16 and 74 years used the Internet in the 3 months previous to the interview and
the devices that are most used to access the Internet were mobile phones or smartphones (78%) [14].
Nowadays, strategies for mobile development can be divided in two main groups: native development and web-
based development. Native mobile apps are developed only for one platform and use programming languages and
tools specific of that platform. For example, an Android native app is developed in Java and uses the Android Software
Development Kit (SDK). Native apps have high performance and good User Experience (UX). However, since code
from a platform can not be reused in another one, it leads to heavy development and high maintenance costs. On the
other hand, web-based development uses web technologies, such as HTML5, CSS and JavaScript, to develop mobile
apps that can work in any mobile platform, overcoming this problem [15, 16, 17].
Web-based development strategies can be divided into three groups: Mobile Web Apps, Hybrid Mobile Apps and
PWAs. Mobile Web Apps are websites optimized for mobile use that are accessed in browsers. Since standard web
technologies are used, the user experience is the same no matter the platform. This allows faster development and
simpler maintenance. Even though these apps can access the camera or the microphone, for example, they fail at
accessing other features. They also struggle with heavy graphics and cannot be distributed in app stores [16]. Hybrid
 Patrícia Loreto et al. / Procedia Computer Science 141 (2018) 525–530 527
Patrı́cia Loreto / Procedia Computer Science 00 (2018) 000–000 3

Mobile Apps have a wrapper that makes them available for distribution in any platform. This wrapper is achieved by
using a hybrid development framework (e.g. PhoneGap) and provides an Application Programming Interface (API)
that matches the requests to their equivalents in the corresponding platform. In this methodology, the same code is
reusable for all platforms allowing simple development and maintenance, but not all native APIs are provided by the
wrapper [16, 18, 19]. PWAs are enhanced Mobile Web Apps. They run as well in browsers, but support other features,
such as push notifications or offline support. They are opened in the browser and ask the user if he wants to install the
app. If the user accepts, the app is added to the home screen and is accessed and used just like a native app [15, 16, 18].
PWAs are better than web apps and can be an alternative to hybrid apps. They have the potential to work in
any mobile device or computer, which neither native apps or hybrid apps can. In fact, some known technological
companies have switched to this methodology. One of these companies is Pinterest. Pinterest realized that their website
only converted 1% of users into signups, logins or native app installs and they wanted to improve these values. The
change from their old mobile site to the new one improved the time spent by users in their website, as well as the core
engagements. The results were even better than the results from their native apps. Aside from this, loading times on
mobile were drastically reduced. By combining other techniques to optimize the app size (e.g. image optimization),
the PWA was much smaller than the native apps as well [20].
Given this, PWAs have the potential to overcome one of the barriers to the adoption of PHRs presented above,
usability and availability. Therefore, the PWA methodology was chosen to develop this PHR.

3. Progressive Web Apps

Progressive Web Apps were first introduced in 2015 and are websites optimized to work on mobile devices [21].
PWAs are available for everyone no matter the browser or device, are installable in the user’s home screen like a
regular app and their content is always displayed properly. They are served through a HTTPS connection and do
not depend on Internet connectivity, because the service worker will handle the app behaviour when offline or on
low-quality networks. The service worker will also make sure the app is always updated and combined with the app
manifest makes the app discoverable in search engines [15, 21, 22].
The first time a PWA is visited it is accessed like any other web app through the browser. Then, the user is prompted
to install the app. This prompt is only fired if the app is not already installed, the user interacted with the app for at
least 30 seconds, it includes a web app manifest with the minimum parameters, is served over HTTPS and has a
service worker registered [23]. If the user accepts the prompt, the app is added to the home screen [15].
The core of a PWA is the service worker. It is a JavaScript file responsible for caching resources and serving
cached resources, which decreases loading time and makes the app capable of working offline, and makes it possible
to use advanced features such as notifications or push messages [21, 24]. The first step in a service worker lifecycle
is Registration. During Registration, the browser is told where the service worker is and to start installing it. When
Registration ends, Installation happens. During the Installation event it is possible to perform some tasks, such as
precaching resources. Finally, Activation happens and the service worker controls all pages and resources within its
scope and listens to events [24].
One of the biggest advantages of PWA is the offline support they provide. As previously explained, this is possible
due to service workers, because they have the ability to use the Cache interface. The storage from the Cache interface
is independent from the browser’s HTTP cache and, therefore, it is available offline. Aside from the cache, service
workers can also use IndexedDB to store data. Using the offline capabilities of PWA, the overall UX improves, since
it results in faster loading [25]. A possible way of enabling offline support is to cache the static data during Installation
and have the service worker listening for resource requests. When a resource is requested, the service worker checks if
it is in the cache and only if the resource is not available, it uses the network. When the last option happens, the service
worker may copy the resource and cache it for later use [25]. There are other strategies to deal with resources, such as
cache only, network only, cache falling back to network, network falling back to cache and stale while revalidate [26].

4. Pregnant Women Health Record Application

In this section the process of creating a PHR for the monitoring of pregnant women using the PWA methodology is
presented. This PHR was developed in partnership with the Centro Materno Infantil do Norte (CMIN), a Portuguese
528 Patrícia Loreto et al. / Procedia Computer Science 141 (2018) 525–530
4 Patrı́cia Loreto / Procedia Computer Science 00 (2018) 000–000

Maternity. This maternity provided all the information displayed in the app, making it a reliable source of information
for pregnant women, and it also allowed us to develop the app taking into account the feedback pregnant women
provided of what they enjoy in the apps they use and what they would like to see in a app.
Given this, the main features that the app provides are:

• A calculator for the due date;

• A calendar where the pregnant woman can save important appointments;
• The ability to save documents, such as ultrasounds or analysis;
• A section of frequently asked questions (FAQs) about the pregnancy and labour that women usually have;
• Personalized health information according to health conditions the pregnant woman might have (e.g. diabetes);
• Information updated weekly about the changes occurring in the pregnant woman’s body and in the fetus;
• The recording of health indicators such as weight, glucose and heart pressure.

For the development of this application, one of the main goals was to make it available for as many pregnant women
as possible so that it could have a wide adoption. Thus, the PWA methodology was chosen. First, a single-page web
application was developed and, for the development, JavaScript-based and open source technologies were chosen:
React for the front end, Node.js with Express.js for the back end and MongoDB as the database. The workflow of
the app is presented in Figure 1. One of the main concerns when developing the web app was to make the front end
responsive, so that pages can adapt themselves to different screen sizes and can work properly on all devices. To
achieve this, Bootstrap was used in the form of React-Bootstrap, a module that joins Bootstrap and React.

Figure 1: Workflow for the developed web app.

After this, the developed web app was transformed into a PWA. To transform the web app into a progressive one,
it was necessary to add a service worker, make it work offline and add an app manifest. The developed service worker
caches assets, such as CSS or JS files, and all the URLs from the web app. When the client requests an asset, the
request is intercepted by the service worker, instead of going directly to the server. Then, the service worker acts on
that request by retrieving data, for example. This makes the app faster. To make sure that assets are updated, a cache
version number is defined. When the service worker becomes active, it checks if there are old caches. If there are,
it deletes the old ones. Still during the Activation stage, the service worker adds some data to IndexedDB. This data
consists of static content that will show up in some pages, for example the FAQs data.
When it comes to working offline, we defined that all URLs should work even if there is no Internet connection,
that the most recent data should always be available and that the woman should only update her data if online. The
first condition was accomplished by precaching all URLs. This condition is specially important on mobile, because
it gives a more native feel to the app if the pregnant woman adds it to her home screen. The second condition,
was accomplished by saving the most recent user data and content on her device and updating it when there is an
Internet connection. Finally, to make the user only update data when online, all the buttons that lead to data update
are disabled and a warning is presented, when there is no Internet connection. An example of the offline capability in
action is presented in Figure 4.
Lastly, the app manifest was added, so that the users can add the app to their home screen on mobile. For the app
manifest, an icon, a name, short name, start url and the display mode (fullscreen) were provided as well as a theme
color and a background color.
 Patrícia
Patrı́cia Loreto
Loreto et al. Computer
/ Procedia / ProcediaScience
Computer Science000–000
00 (2018) 141 (2018) 525–530 529
5

(a) Online. (b) Offline.

Figure 2: The same page when the user is online and offline. When the user is offline, all buttons that edit or add data are disabled and a warning is
presented. Still, the data that was available when the user was online for the last time is displayed.

5. Discussion

The developed system has both strengths and weaknesses. One of the factors that may difficult the adoption of this
app is browser compatibility. This is not an issue if the user uses Google Chrome, because the main driver behind
PWAs is Google. For other platforms, this issue tends to decrease over time. For example, with the latest release of
iOS Safari in last March (version 11.3), service workers are now compatible. Even though the app works offline, there
are some features available only online. This could be solved using the Background Sync API, but it is not available in
some browsers (e.g. Safari), so the work that would be applied to enable these functionalities would not pay off at the
moment. However, if this API starts having a more wide spread adoption this may be an interesting area to improve.
The app works on all devices as long as there is a browser and adapts itself to different screen sizes. On computers,
it works as any other website with the advantage of loading faster after the first visit, since all required resources are
cached. On mobile, users can either open it in the browser or add the app to the home screen like a mobile app from
the app stores. In both cases, it works offline and has a wide range of features available. The availability in such a
wide range of devices may have a positive impact in the adoption of the developed PHR, which was one of the main
problems to the adoption of these records. If the user adds the app to the home screen, the access to the app becomes
easier and it will look like a native one, since it has a splash screen and is displayed in fullscreen. This, combined with
the fact that the app is responsive, improves the UX and gives a more native look to the app.
Since the app was developed taking into account feedback from pregnant women, it was designed with features
that they find interesting and useful. The development process also had the help of a medical institution that provided
reliable information for the pregnant women. These two conditions combined have the potential to engage pregnant
women more and turn them more active in their pregnancy management, which may impact positively birth outcomes.

6. Conclusions and Future Work

In this paper a PHR for the support of pregnant women is presented. This PHR is a PWA, which means that it is an
enhanced web app. This development methodology makes the same web app available on computers and on mobile
phones and has proved to improve user engagement. This was one of the reasons why this methodology was chosen,
since PHRs need to find a solution that reaches as many individuals as possible. PWAs can also cache resources,
which makes the app faster and able of working offline. The developed PHR was also designed with the support of
a medical institution and taking into account feedback provided by pregnant women. This allowed the app to display
trustworthy information and to have a set of features that pregnant women find useful. Some of the features provided
are a calendar for appointments, weekly information on fetus development and the tracking of some health indicators.
In the future, a usability test should be performed so that the app can be evaluated and improvements can be made.
It would also be interesting to study the adoption of this app by pregnant women and the impact that it has in their
engagement and birth outcomes.
530 Patrícia Loreto et al. / Procedia Computer Science 141 (2018) 525–530
6 Patrı́cia Loreto / Procedia Computer Science 00 (2018) 000–000

Acknowledgements

This work has been supported by Compete: POCI-01-0145-FEDER-007043 and FCT within the Project Scope
UID/CEC/00319/2013.

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