JMIR FORMATIVE RESEARCH

Lipson-Smith et al

Original Paper

Co-Design of a Consultation Audio-Recording Mobile App for
People With Cancer: The SecondEars App
Ruby Lipson-Smith1, BA, BSc (Hons); Fiona White, BA; Alan White, Grad Dip Counselling; Lesley Serong, BEd;
Guy Cooper2, BComm; Georgia Price-Bell2, BCommDes; Amelia Hyatt1, BA (Hons)
1

Cancer Experiences Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia

2

Wave Digital, Melbourne, Victoria, Australia

Corresponding Author:
Amelia Hyatt, BA (Hons)
Cancer Experiences ResearchPeter MacCallum Cancer Centre
305 Grattan Street
Melbourne, Victoria, 3000
Australia
Phone: 61 3 8559 7837
Email: amelia.hyatt@petermac.org

Abstract
Background: Many patients choose to audio-record their medical consultations so that they can relisten to them at home andshare them with family. Consultation audio-recordings can improve patients’ recall and understanding of medical informationand increase their involvement in decision making. A hospital-endorsed consultation audio-recording mobile app would provide
patients with the permission and means to audio-record their consultations. The Theory of Planned Behavior provides a framework
for understanding how patients can be encouraged to appropriately audio-record consultations.
Objective: The aim of this study was to use a co-design process to develop a consultation audio-recording mobile app called
SecondEars.
Methods: App development began with stakeholder engagement, followed by a series of 6 co-design workshops and then user
acceptance testing. Stakeholder engagement included advice from legal, information technology (IT), clinical and allied healthleads; digital strategy; and medical records. he co-design workshops were attended by: patient consumers, members of the researchteam, IT staff, the app designers, clinicians, and staff from medical records. During workshops 1 to 4, the purpose and scope of
the app were refined, possible pitfalls were addressed, and design features were discussed. The app designers then incorporated
the results from these workshops to produce a wireframe mock-up of the proposed SecondEars app, which was presented for
feedback at workshops 5 and 6.
Results: The stakeholders identified 6 requirements for the app, including that it be patient driven, secure, clear in terms oflegal responsibilities, linked to the patient’s medical record, and that it should require minimal upfront and ongoing resources.
These requirements informed the scope of the co-design workshops. The workshops were attended by between 4 and 13 people.
The workshop attendees developed a list of required features and suggestions for user interface design. The app developers used
these requirements and recommendations to develop a prototype of the SecondEars app in iOS, which was then refined throughuser acceptance testing.
Conclusions: The SecondEars app allows patients to have control and autonomy over audio-recording and sharing theirconsultations while maintaining privacy and safety for medical information and legal protection for clinicians. The app has been
designed to have low upkeep and minimal impact on clinical processes. The SecondEars prototype is currently being tested withpatients in a clinical setting.
(JMIR Form Res 2019;3(1):e11111) doi: 10.2196/11111
KEYWORDS
referral and consultation; adult; humans; cancer; audiovisual aids; mobile apps; community-based participatory research; healthbehavior; psychological theory

http://formative.jmir.org/2019/1/e11111/

XSL• FO
RenderX

JMIR Form Res 2019 | vol. 3 | iss. 1 | e11111 | p. 1
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH

Introduction
Background
Facilitating Patient-Centered Care
Shared decision making and patient participation are essential
elements of patient-centered care [1]. However, patientparticipation is reduced when patients do not understand or
remember information given to them by their health care team[2]. Patients’ ability to retain health care information can becompromised if the patients have low health literacy or language
barriers or if the information is complex or distressing [3-5].
Consultation audio-recordings are an effective method toimprove patients’ recall and understanding of medical
information and subsequently increase their involvement indecision making [6-10].

Smartphones for Consultation Audio-Recording
With the increase in smartphone ownership, patients are taking
the initiative to audio-record their medical consultations
themselves [11]. Recording of consultations is predominantly
undertaken because of a desire to increase understanding andto facilitate discussions with family [12], but only a few healthcare systems have recording policies in place and patientssometimes audio-record consultations without their clinician’s
knowledge [13,14]. Patients have therefore self-identified aproblem in their care—namely, their lack of understanding andrecall of medical information—and a solution to this problem:
mobile health (mHealth) technology. Furthermore, patients haveexpressed a desire for health care providers to institute clear,
permissive strategies to facilitate consultation audio-recording[12]. Previous studies have also emphasized the patients’ desire
to control which consultations are audio-recorded [5]. Cliniciansand health care providers must now work with patients toimplement official systems of consultation audio-recording tofacilitate an environment where audio-recording is openly
encouraged. Medico-legal and trust concerns may be a barrierfor some clinical staff regarding participation in consultation
audio-recording [15]. An official consultation audio-recording
system, such as a suitable smartphone app, may mitigate any
potential fear or mistrust that could emerge between the patientand clinician as a result of audio-recordings. A suitableconsultation audio-recording smartphone app would promoteresponsible use of consultation audio-recording, meet relevant
legal requirements, and align with patient-centered care byplacing control in the hands of the patient.
Previous consultation audio-recording studies have utilized
digital recorders or Dictaphones operated by hospital staff, anda copy of the audio-recording was then given to the patient totake home on an audiotape, CD, or USB [16-19]. Dictaphones
require resource-intensive setup and maintenance by staff. The
administrative load of this system prohibits implementation into

http://formative.jmir.org/2019/1/e11111/

XSL• FO
RenderX

Lipson-Smith et al
usual care, and it prevents patient control over theaudio-recording. Clinicians and hospital administrators
understand that consultation audio-recordings are beneficial forpatients, but they emphasize that successful implementation
would require a system that (1) has low upkeep with minimalburden on clinical processes and resources, (2) addresses
medico-legal concerns, (3) clearly defines who is responsible
for the audio-recording once it is made, and (4) responds topatient preference by allowing the patients to control when theyaudio-record and with whom they share the audio-recording[11,15].

Co-Design of a Smartphone App
If a consultation audio-recording app is to meet the needs ofpatients, family, clinicians, and hospital administrators, allstakeholders must be involved in the app design anddevelopment [20]. Experience-based co-design is the process
whereby future end users and other stakeholders draw on theirexperience and work with designers to design a product orservice [21,22]. The experience-based co-design approach
applies the key tenets of patient participation. Patients, as experts
in their care, are involved in all facets of the project fromsolution generation, project design and oversight, through todesign and testing. Patients have already identified smartphones
as a means to audio-record their consultations [11,13,14]. The
aim of this study was to use experience-based co-design todesign a consultation audio-recording mobile app called
SecondEars that utilizes this patient-identified solution whileworking to meet the implementation requirements identified byclinicians and hospital administrators.

Objectives
The objectives of this co-design study were to:
1.
2.
3.
4.
5.

Identify and engage the stakeholders integral to
implementation of mHealth technology within a hospital.
Facilitate co-design workshops to identify the necessary
features of the app.
Develop a wireframe of the app.
Conduct user acceptance testing of the app.
Complete a prototype of the app.

Future publications will report on the piloting andimplementation of the SecondEars app into usual care.

Methods
Study Design
This study was conducted at the Peter MacCallum Cancer Centre(Peter Mac) in Melbourne, Australia, and was approved by therelevant ethics committee (reference number: 16/07L).
Objectives 1 to 5 were met via the co-design process outlinedin Figure 1. All workshop attendees provided written informed
consent.

JMIR Form Res 2019 | vol. 3 | iss. 1 | e11111 | p. 2
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH

Lipson-Smith et al

Figure 1. The co-design process for the SecondEars consultation audio-recording app.

Theory of Planned Behavior
The Theory of Planned Behavior provided a framework for thedesign and future implementation of the SecondEars app. The
Theory of Planned Behavior posits that a person’s behavior is
directly related to the person’s intentions, which in turn result
from subjective norms, beliefs, and perceived control over the
behavior [23]. If the patients are to be encouraged to responsibly
audio-record consultations, the following should be addressedin the design of the SecondEars app:
1.
2.
3.

Clinicians’, hospital administrators’, and patients’ beliefs
about consultation audio-recording
Patients’ perceived control over audio-recording
The subjective norms of consultation audio-recording

Apps are user-controlled; it would be up to the patients todownload and use an app on their own device, thereby
supporting perceived control. An app can be promoted by thehospital, giving patients permission to audio-record openly,
thereby developing a subjective norm. An app could also link
audio-recordings to the hospital’s medical record or information
technology (IT) systems and allow patients to share theaudio-recording with family or friends, indicating the safety
and utility of audio-recordings, which may change clinicians’,
hospital administrators’, and patients’ beliefs about consultation
audio-recording.
A well-designed consultation audio-recording mobile app could
therefore positively influence behavioral, normative, and control
beliefs and, according to the Theory of Planned Behavior,change intentions and encourage responsible audio-recording
behavior.

Stakeholder Engagement
Initial consults with key stakeholders began in 2016 andcontinued throughout the development process. This early
engagement informed the legal and technical requirements of
the app before commencing the co-design process (see theResults section for a summary of these requirements). The
following 16 stakeholders were consulted: 2 members of thehospital’s legal department, 4 members of the IT department,
including the head of department, 5 clinical and allied health
http://formative.jmir.org/2019/1/e11111/

XSL• FO
RenderX

leads, the director of digital strategy, the head of the medical
records department, and 3 consumer advocates. These
stakeholders were kept informed throughout the development
process and some attended workshops. The consumer advocatesalso took a formal place within the project steering committee
as associate investigators. The proposed requirements of theapp were reviewed and approved by the New Technology
Review Committee at Peter MacCallum Cancer Centre in
December 2016.

Developer Engagement
A local mobile app development company, Wave Digital, wascontracted in February 2017 to create the SecondEars app. Wave
Digital readily embraced the co-design approach and used
elements of the Design Sprint methodology to structure thedesign process [24].

Co-Design Workshops and Activities
A total of 6 co-design workshops were held between April andJune 2017 (see Figure 1). Some of the methods used to elicit
information during the workshops included frequently asking
open and obvious questions such as “Why.” In addition,
rephrasing assumptions or problems as questions was criticalto accurately capture the goals for the product and identify the
problem the product was attempting to solve.

Stage 1: Goals, Problem Definition, and Assumptions
to Test (Workshops 1-3)
Before the first workshop, the attendees were briefed on therationale for developing the SecondEars app, the proposed
primary functions of the app, and the requirements andconstraints that had been identified by the key stakeholders.
The following 3 questions were addressed in workshops 1 to 3:
1.
2.
3.

What do we want the app to do?
How can we imagine the app failing?
Who will be involved in using the app?

To address question 1, the attendees brainstormed a list offunctions that the app should be able to do; this list wasiteratively added to and refined throughout workshops 1 to 3.
To address question 2, the attendees identified possible reasonsthat the app may fail and then reframed these potential pitfalls
JMIR Form Res 2019 | vol. 3 | iss. 1 | e11111 | p. 3
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH

Lipson-Smith et alas knowledge-seeking questions. These knowledge-seeking
questions were used as starting points to generate strategies that
could be employed to prevent the potential pitfalls. To define
who would be involved in using the app (question 3), a
technique called Journey Mapping was used, and the attendees
mapped out the pattern of use for the app in the broader context
of the patient’s journey through Peter Mac. This included how
and when a patient may become aware of it; how and when they
may download it; who may encounter the app before, during,or after the patient’s hospital consultation; and who may listen
to the audio-recording.

Development and User Acceptance TestingStage 2: Solution Inspiration and Prioritization(Workshop 4)

Iterative Refinement

During workshop 4, attendees compiled a list of existing appsthat they believed were well designed, intuitive, or provided aunique experience. These apps were then used to provide
inspiration for the user interface design of the SecondEars app.
The co-design team used the MoSCoW method [25] to prioritize
the desirable functions that had been identified during
workshops 1 to 3. MoSCoW stands for the following:must-haves (Mo), should-haves (S), could-haves (Co), andwon't-haves (W). This method allowed the attendees to reacha common understanding of the scope of the project and therelative importance of each of the functions that were listed
during workshops 1 to 3.
Following workshop 4, the app developers used a techniquecalled wireframing to do the following:
1.
2.
3.

Structure the composition of the features and functions of
the app (as prioritized during workshop 4).
Prioritize the content on those interfaces.
Connect the interfaces into a logical user flow.

Stage 3: User Experience Design (Workshops 5 and 6)
In workshop 5, the proposed designs for the app were presented
in paper form using a series of interfaces cut to size. The
feedback from this workshop informed the wireframes of theapp. These wireframes were presented on an iPhone in workshop
6. The app developers conducted one-on-one user experience
feedback sessions with each of the attendees to gauge eachattendees’ thought process and responses to using this wireframe
design. Each attendee was given the wireframe app on an iPhone
and asked to complete the following 4 tasks without prompting:
1.
2.
3.
4.

Make an audio-recording and then listen back to it.
Write a note on one of the recordings.
Read previously made notes while recording a consultation.
Log out of the app.

User Interface Design
The final stage of the design process was to create a visual
identity for the SecondEars app. The combination of a logo,
color, typography, and iconography was developed during thedesign process. Those brand elements were then applied to theinterfaces of the SecondEars app, incorporating all feedback
gathered during the sixth co-design workshop.

http://formative.jmir.org/2019/1/e11111/

XSL• FO
RenderX

Wave Digital used the finalized visual designs to develop a
prototype of the app. Immediate feedback from the researchteam was incorporated and, in September 2017, the refined
prototype was released to the co-design team for user acceptancetesting so that any bugs could be identified. All faults were thenrectified before the SecondEars app was made available in Test
Flight mode on the Apple App Store.

Results
Each stage of the development process resulted in requirements
and refinements that were incorporated into the final design of
the SecondEars app. The outcomes of each stage of thedevelopment process are outlined below.

Requirements Identified Through Stakeholder
Engagement
The requirements identified by the stakeholders are outlined inTable 1. These requirements established the design profile andconstraints of the SecondEars app and provided a foundation
for the workshops.
To meet requirement 6 (see Table 1), the research team choseto develop a minimum viable product and assess its successbefore making additional financial investment. For this reason,some aspects of requirement 5 were not addressed in this versionof the app. Specifically, the research team decided not toautomate the app’s connection to the medical record until theapp had been piloted within clinical care. If piloting indicateshigh uptake of the app, then the investment in the IT
infrastructure necessary to securely and automatically upload
the audio-recordings to the medical record would be justified.
In the interim, the audio-recordings would be securely hosted
through a cloud solution (Amazon Web Servers) with aninterface to allow the medical record staff to access theaudio-recordings and manually upload them to the patient’s
medical record if necessary, thus meeting requirement 3. The
research team identified a potential tension between requirement
1 and requirement 3: if the app is entirely patient driven, thenthe responsibility of uploading the audio-recording to the
medical record falls to the patient. This process could not be
automated; therefore, the research team introduced a requirementthat all audio-recordings must be uploaded before they can beplayed back or shared by the patient.
In response to requirement 6, the research team decided tofurther reduce upfront costs by initially creating the app in iOS
for iPhone, not Android. App development in Android is more
complex and costly as the app design must be tested on a larger
number of Android devices, whereas iOS can be developed for
1 platform only. Developing for iOS first enables more feedback
to be gathered from users and any issues addressed before
investing in an Android version. It was therefore pragmatic todelay releasing the app in Android until it had been piloted in
iOS.

JMIR Form Res 2019 | vol. 3 | iss. 1 | e11111 | p. 4
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH

Workshop Attendees
Each workshop was attended by between 4 and 13 people who
together comprised the co-design team. The co-design teamincluded the following: patient consumers, members of theresearch team, representatives from IT, app designers, clinicians,
hospital volunteers, and a representative from the medical
records department. Table 2 shows the number and type of
attendees at each workshop. One consumer attended 4 of the

Lipson-Smith et alworkshops (female, 56 years of age, previous experience asboth a patient and a carer, and self-identified as having
intermediate technology skills). Another consumer attended 2of the workshops (male, 66 years of age, previous experienceas both a patient and a carer, and self-identified as having
intermediate technology skills). The third consumer attended
the final workshop (female, 64 years of age, previous experience
as a carer, and self-identified as having beginner technology
skills).

Table 1. The requirements of the app identified through stakeholder engagement.
Requirement

Description of requirement

1. Patient-driven

The app should be used by patients, not hospital staff; If The patient must be able to source, download, and use
the patient’s clinician has given permission to be audio- the app independently, with minimal input from hospitalrecorded, the patient should have ultimate control over
staff
when and how the patient uses the app; This is not only
important in terms of patient participation but also forpracticality and financial feasibility of the app (see requirement 5)

2. Secure

The audio-recordings saved on the app and shared fromthe app must be secure as they will contain identifiable
information

Access to recordings should be given only to users of thesystem via Secure Sockets Layer; The actual recording
files should never be sent via unsecure means (eg, shortmessage service, email); Strong password policy for Admin access

3. Linked to medical record

Consultation audio-recordings should be considered apart of the patient’s medical record; Saving original copiesof the audio-recordings on the patient’s medical record
may help guard against tampering or misrepresentationin the case of a malpractice lawsuit

An original copy of all audio-recordings made on the app
should be stored in the appropriate patient’s electronic
medical record, or in a secure location that is accessible
by medical record staff

4. Clear legal responsibilities

Patients using the app must be aware that they are legally Include statement of responsibility on the opening screen
responsible for the safety of the audio-recordings that are of the app and in all app promotion material
saved on and shared from their mobile, just as they are
responsible for any copy that they are given of any component of their medical record

5. Minimal upkeep

Once developed and implemented into usual care, the app Integrate the app into existing hospital procedures; Autoshould require minimal input from the staff and minimal mate processes where possible (eg, automatic upload ofongoing financial costs
recordings from the app to the medical record); Use thelatest secure cloud infrastructure to keep ongoing costs
down

6. Minimal upfront costs

Additional funding could not be sought until the app had
been piloted in a clinical setting and evidence was obtained about the usability of the app, whether it met requirements 1 to 5, and the extent of uptake among patients

http://formative.jmir.org/2019/1/e11111/

XSL• FO
RenderX

Suggested means to meet the requirement

Develop a minimal viable product. Results of the pilot
can then be used to refine the product and support further,ongoing funding; Develop in iOS only (not Android);
Delay investing in automating processes until after piloting

JMIR Form Res 2019 | vol. 3 | iss. 1 | e11111 | p. 5
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH

Lipson-Smith et al

Table 2. The number and type of attendees at each workshop.
Category

Workshop 1

Workshop 2

Workshop 3

Workshop 4

Workshop 5

Workshop 6

Researcher

2

2

2

2

2

2

App developer

2

2

2

2

2

2

Consumer

2

1

1

0

0

3

Information technology

1

0

0

0

0

1

Oncologist

0

0

0

0

0

1

Nurse

0

0

0

0

0

1

Allied health

0

0

0

0

0

1

Medical records

0

0

0

0

0

1

Hospital volunteer

0

0

0

0

0

1

Total

7

5

5

4

4

13

Outcomes From Workshops 1 to 4
In answer to question 1 (“What do we want the app to do?”),the attendees took a blue sky thinking approach and articulated
an ultimate aim for the app, as well as a list of all possiblefunctions. The ultimate aim of the app was unanimously decided
and described as “Improve the quality of patients’ care,” thatis, improving the quality of patients’ participation, understanding
and support during treatment, diagnosis, decision making, andsupport during their cancer journey. This was used as a keystone
upon which to design the app and guide decision making
regarding design, functionality, and utility. The possiblefunctions identified by the attendees included the following:audio-record, share audio-recordings, listen back toaudio-recordings, use without help, secure, categorize and label

audio-recordings, send audio-recordings to Peter Mac, makenotes, and read notes.
Table 3 summarizes the potential pitfalls and corresponding
preventative strategies that were identified by the workshop
attendees in answer to question 2 (“How can we imagine theapp failing?”). This exercise indicated that, to be successful,the app would need to be paired with a promotion and education
strategy to teach patients how and when they should use theapp, their rights and responsibilities regarding use and sharingof audio-files, and to build trust with clinical staff.
In answer to question 3 (“Who will be involved in using theapp?”), the attendees mapped out a typical patient journey within
the hospital, identifying the key interactions that all personnel
would have with each other and the app (see Figure 2).

Table 3. The potential pitfalls, knowledge-seeking questions, and preventative strategies outlined in workshops 1 to 3.
Potential pitfalls

Knowledge-seeking question

Preventative strategy

1. The app is too difficult to use

How do we make the app intuitive to the patient, thecarer, and the health care community?

User-friendly, simple design; Education on how to use(provided with appointment booking information);
Volunteer assistance in clinic

2. The app leads to incidents ofpersonal damage (eg, security
breaches)

How do we gain and maintain trust?

Appropriate security infrastructure; Education on responsible sharing (presented at app log-in); Upload to medical record required before play back or sharing

3. Patients do not download theapp

How do we support appropriate and wide distribution? Promotion (notification with appointment booking, signs
in waiting room, and encouragement from the staff)

4. Patients forget to use the app

How do we let everyone know when it is the right time Promotion (notification with appointment booking, signs
to use the app?
in waiting room, and encouragement from the clinicalstaff)

5. Patients do not find the app
usefulHow do we align the service to the benefits of audiorecordings that have already been established throughresearch?

http://formative.jmir.org/2019/1/e11111/

XSL• FO
RenderX

Draw on existing research; Include consumers in development

JMIR Form Res 2019 | vol. 3 | iss. 1 | e11111 | p. 6
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH

Lipson-Smith et al

Figure 2. A journey map representing the envisaged pattern of use of the SecondEars consultation audio-recording app.

http://formative.jmir.org/2019/1/e11111/

XSL• FO
RenderX

JMIR Form Res 2019 | vol. 3 | iss. 1 | e11111 | p. 7
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH

Lipson-Smith et al

Textbox 1. The features that could be included in the SecondEars app and their corresponding prioritization according to the MoSCoW (Must have,Should have, Could have, and Won’t have) method.
Must have•

Record consultation•

Upload required before playback•

Playback recording•

Patient identification number required for log-in•

Explain legal context and provide instructions•

Delete recording•

Share recording•

Recording library (list)•

Peter Mac access to data (list of recordings to download and attach to medical record)

Should have•Notes on playback (editable)•

Notes while recording (view only)•

Categorize recordings (colors or tags)•

Ability to associate each recording with the relevant clinician (ie, tag recording as Physio, doctor, and nurse)

Could have•

Capture next appointment•

Reminder notification of next appointment

Won’t have•

Authenticate and user management•

Booking system integration•

Push notifications and reminder emails•

Upload over 3G, Wi-Fi setting (user controlled)•

Barcode or quick Response code scan•

Access recording and share recording without device

Figure 2 shows that the initial promotion of the app would need
to be undertaken by the administration staff. Information about
the app would be provided to the patients by the administration
staff when their first appointment is booked. The patients would
then download the app before their first consultation (or“encounter”) at the hospital. Hospital volunteers, who are aregular presence at Australian hospitals, would be made awareof the app and be available to assist patients in downloading it
while the patients wait for their appointment. The patients may
then use the app to audio-record the nurse and/or specialist
during their first consultation and at subsequent consultations.
The pattern of use also shows that the patients may share theaudio-recordings with their family members or friends after
their hospital encounter. According to the Theory of Planned
Behavior, integrating the app into the clinical process could
influence subjective norms and therefore influence the patients’behavior.
During workshops 1 to 3, additional features were suggested
as complements to the audio-recording functionality in the app,and suggestions were made regarding how patients could label,
http://formative.jmir.org/2019/1/e11111/

XSL• FO
RenderX

categorize, store, share, and search for audio-recordings once
they are made. These features are listed in Textbox 1 along with
their priority according to the MoSCoW exercise that wascompleted in Workshop 4. The features classified as “Musthave” or “Should have” were considered within the scope of
the app. These features were included in the wireframe of theapp, which was trialed in workshops 5 and 6.

Outcomes of Workshops 5 and 6
Feedback from workshop 5 informed the development of thewireframe, which was presented on an iPhone in workshop 6.
The members of the co-design team attended workshop 6, anddecisions from workshops 4 and 5 were reviewed at the start of
the workshop. A total of 9 members of the co-design team trialed
the wireframe of the app in workshop 6 (see Table 2). The 2
researchers and the 2 app developers did not trial the wireframein this workshop as they had viewed the designs in workshop
5 and were not the intended users of the app. The wireframe
contained all app content but without the colors, etc, of a final
version. All attendees completed the 4 tasks without prompting.
JMIR Form Res 2019 | vol. 3 | iss. 1 | e11111 | p. 8
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
Their feedback suggested that the app was “quite
straightforward” to use (consumer). Suggestions were also madeto further improve usability. A clinician suggested that the fontsize be increased (“I couldn’t read that without my glasses on”);
therefore, the app was adjusted to automatically match the fontsize settings on the user’s phone. Another clinician suggested
placing the play symbol (a triangle) inside a circle so that it
looked more like a button. Moreover, 1 clinician and 1 consumer
suggested that app users should be able to navigate back to the
instructions page if they want a reminder of how to use the app(the wireframe displayed the app-use instructions only once,
immediately after log-in). The representative from medical
records suggested an amendment to the terms and conditions.
Several attendees suggested adding an open category in thelabeling function so that patients can assign their own labels torecordings or note if more than 1 clinician was present at theappointment.
Some extra features were also suggested, which were shelved
for later iterations. A clinician suggested allowing patients to
attach photos to audio-recordings; she often draws pictures to
explain medical procedures to patients or shows them scans thatthey may want to photograph. Several people suggestedchanging the notes feature so that the user could create notesthat were not related to a specific audio-recording or, conversely,
to link notes to a particular section (ie, minute and second) ofan audio-recording.
After prioritizing all the feedback generated from workshops 5
and 6, the wireframes were adjusted to enhance the navigationand layout. The hierarchy of the individual recordings screen
was reconsidered to place a stronger focus on the core featureof listening to an audio-recording. Additional smaller changes
were made to increase the overall accessibility of the app,
resulting in an experience that was more intuitive and easier tonavigate.

User Acceptance Testing
Wave Digital incorporated the feedback from workshops 5 and6 into the visual interface design of the app to develop a
prototype for user acceptance testing. Unlike the wireframe,
this prototype contained all the design features and was, inessence, a complete app. Overall, 7 people tested this prototype:2 clinicians, 4 researchers, and 1 consumer. Feedback included
the following: bugs or defects (eg, typos or unexpected error
messages), design-related feedback (eg, recommendations forconsistency of the exit and back buttons), suggestions forchanges to written content or copy, and feedback relating to theuser interface for the Amazon Web Server (eg, allowing audio
files to be deleted by the administrator).

The Final App Design
The feedback from user acceptance testing was incorporated
into a final version of the app. The design of this version of theapp is included in Multimedia Appendix 1 and its functionality
is listed in the Must have and Should have sections of Textbox
1.

http://formative.jmir.org/2019/1/e11111/

XSL• FO
RenderX

Lipson-Smith et al

Discussion
The SecondEars App
The SecondEars consultation audio-recording app for cancer
patients was successfully co-designed and a prototype wasdeveloped in iOS. This mHealth patient-identified solution has
been designed to facilitate its implementation in a clinical setting
and has been developed within a framework of the Theory ofPlanned Behavior. The app enables a copy of eachaudio-recording to be saved on the appropriate patient’s medical
record, thereby allowing the hospital to retain access to theoriginal recording for medico-legal reasons. This balance
between patient autonomy and clinician security was achieved
through stakeholder engagement, co-design workshops, anduser acceptance testing to ensure that SecondEars was designed
to meet the requirements of all users. Furthermore, the app was
designed to have low upkeep and minimal burden on clinicalprocesses.

Principal Findings
Most of the requirements identified through stakeholder
engagement echo the findings from Moloczij et al [15] and van
Bruinessen et al [11] regarding barriers and facilitators to
implementation (summarized in the Introduction of this paper).
Stakeholders in this study emphasized the importance ofminimizing upfront costs. This requirement led to thedevelopment of a pragmatic, minimum viable productcomprising only the essential core features. The first co-design
workshop confirmed that the aim of the app is to “improve
patient care.” This impetus, and the MoSCoW session inworkshop 4, worked to focus the app development on the mostimportant features: audio-recording and sharing theaudio-recording securely and confidentially. Paring back theapp to contain only essential features ensures will help tominimize upkeep and keep the app cost-viable for a public healthcare setting. Further features can be adapted and expanded in
the future as the feasibility and efficacy of the app become
established through the evaluation of implementation in aclinical setting.
SecondEars was designed to strike a balance between 2
imperatives that, at times, could come into conflict: patientautonomy over the audio-recording and legal protection for theclinician. Our stakeholders identified that medical information
provided by the doctor would form a part of the medical record,
which prompted a solution that met both of these imperatives:compulsory uploading of audio-recording before playback andsharing would provide the clinician with a measure of security
while maintaining the patient’s control over the creation anddistribution of the audio-recording.
Furthermore, useful data were generated regarding practical
recommendations to facilitate implementation after piloting.
The second and third co-design workshops confirmed that theapp would need to be distributed with publicity and education
information to ensure timely uptake of the app, which is in linewith the Theory of Planned Behavior. The patient journey map
revealed how many different types of people would encounterthe app, suggesting that an app can be a means to change
subjective norms.
JMIR Form Res 2019 | vol. 3 | iss. 1 | e11111 | p. 9
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
A recent systematic review found that health care apps are more
likely to be effective if they are user-friendly and require
minimal time investment [26]. This is in line with the perceived
behavioral control aspect of the Theory of Planned Behavior;people will be more likely to take up a behavior if they feel thatthey do not have external time pressures and if they believe thatthey are capable of the behavior. User acceptance testing
demonstrated that testers found the app easy to use. The app iscurrently being piloted in a wider patient population in a clinicalsetting to determine feasibility and ease of use.

Limitations
This study’s strength lies in its theoretical basis and the extent
of stakeholder and consumer engagement. The researchers choseto include multiple stakeholders and not just consumers. This
had benefits in terms of practical recommendations andrequirements for the app. However, the inclusion of multiple
stakeholder groups meant that the number of people in eachgroup had to be limited to maintain a manageable number ofattendees for the workshops. The contributions of consumers
were emphasized throughout (there was a higher proportion of
consumers on the co-design team compared with the otherstakeholder groups); unfortunately, because of schedulingconflicts, the MoSCoW session in workshop 4 was attended byonly the researchers and app developers. Future co-design
research should ensure that the entire co-design team is involved
when features are prioritized. Future studies could also choose
to repeat workshops to provide more opportunities for
consumers to be involved. This approach would increase thenumber and diversity of the consumers in the co-design team(eg, wider range of ages, ethnicities, and time since diagnosis),but it may result in each consumer individually having less input
overall.
Financial and pragmatic constraints identified throughstakeholder engagement mean that the app was developed for
iOS only, not Android. This may introduce a perceived external
control for patients who do not have the necessary equipment
to use the app, which, according to the Theory of Planned
Behavior, may negatively affect behavior change. The numberof patients who are ineligible to participate in piloting becauseof not having an iPhone will be recorded. The drawbacks ofhaving the app on only 1 platform will be temporary as the app
will be adapted for Android once the current design has been
piloted in a clinical setting.
Although the Theory of Planned Behavior is generally awell-accepted theory of behavior change and has been used todesign many behavior change interventions, there have been
inconsistent results regarding its effectiveness, [27,28] anddebate continues around the use of the theory in this context[29,30]. Future researchers can refer to a recent report toconsider the full suite of options for behavior change
frameworks for intervention development [31].

Comparison With Previous WorkTo the authors’ knowledge, no other consultation
audio-recording apps have been developed via a co-design
approach. Previous research has successfully used the Theory

http://formative.jmir.org/2019/1/e11111/

XSL• FO
RenderX

Lipson-Smith et alof Planned Behavior as a guide for developing health careinterventions [32], and other apps have successfully beendeveloped following a behavior change theory [33].
Some of the desired features, such as the app’s automatedintegration with the medical record, are very complex. Other
studies have also encountered similar problems when trying tointegrate an app with the medical record [34]. The pragmatic
choices made in this project will allow the app to be piloted ina clinical setting before significant investment is made tointegrate it with the medical record.

Future Research
The SecondEars app is currently being piloted with patients ina clinical setting. Feedback from patients and clinicians will
inform any further design changes that need to be made before
implementing the app as part of usual care at Peter Mac. Piloting
will also inform the education and promotion strategy that was
identified as important during the development process. Upon
implementing the app, data could be collected regarding
behavior change (uptake, use, etc) to evaluate the success of
the app.
Clinical staff have expressed concern regarding potentialchanges in communication caused by the act of recording a
consultation, such as loss of rapport-building, and reduced
personalization of information delivery, as fear of litigation may
drive information delivery rather than patient need [6].
Longitudinal evaluation of SecondEars implementation could
identify whether these changes occur and whether they aresustained as the app becomes a familiar and routine componentof care. Longitudinal evaluation could also provide opportunities
to study the impact that the SecondEars app has on patients’recall and understanding of medical information and their
participation in clinical decision making.
Future versions of the app should include interface options for
specific patient groups, such as translations and adaptations for
culturally and linguistically diverse patients, and text-to-voice
options for patients who are visually impaired. Furthermore,
there are potential, unexplored benefits to the SecondEars appthat could be investigated in future studies. For example, theconsultation audio-recordings could provide professional
development opportunities for clinicians or teaching
opportunities for clinical students. Other studies have also
discussed the potential cross-professional use of consultation
audio-recordings as a helpful mechanism of informationtransmission between primary and tertiary settings [6].

Conclusions
The SecondEars app has been designed to be a viable andcost-effective means of integrating consultation audio-recordings
into an oncology setting. The app embraces existing technology
as a patient-driven solution to improve patient-centered care.
Engagement of stakeholders and consumers in the co-design
process ensured that barriers to implementation were addressed
and facilitators were leveraged. The SecondEars prototype iscurrently being piloted with patients in a clinical setting before
implementation.

JMIR Form Res 2019 | vol. 3 | iss. 1 | e11111 | p. 10(page number not for citation purposes)

JMIR FORMATIVE RESEARCH

Lipson-Smith et al

Acknowledgments
FM, AW, and LS were consumer advisors for this research and were integral to the development of the SecondEars app.
The authors sincerely thank all the stakeholders and workshop attendees for their time and input in the development of theSecondEars app. The authors thank the staff of Cancer Experiences Research, Peter MacCallum Cancer Centre, and Wave Digitalfor their support in facilitating this project.
This research was supported by the Peter MacCallum Cancer Foundation and Cancer Experiences Research, Peter MacCallum
Cancer Centre, and grants from the Victorian Managed Insurance Authority.

Conflicts of Interest
GC and GP-B are employees of Wave Digital, and RL-S and AH are employees of Peter MacCallum Cancer Centre. Wave Digitaland Peter MacCallum Cancer Centre may benefit financially if the SecondEars app is commercialized in the future.

Multimedia Appendix 1
Screenshots of the SecondEars app design.
[PDF File (Adobe PDF File), 3MB-Multimedia Appendix 1]

References
1.

2.
3.
4.

5.

6.

7.

8.

9.
10.

11.
12.
13.

14.

Castro EM, Van Regenmortel T, Vanhaecht K, Sermeus W, Van Hecke A. Patient empowerment, patient participation andpatient-centeredness in hospital care: a concept analysis based on a literature review. Patient Educ Couns 2016
Dec;99(12):1923-1939. [doi: 10.1016/j.pec.2016.07.026] [Medline: 27450481]
Gattellari M, Butow PN, Tattersall MH. Sharing decisions in cancer care. Soc Sci Med 2001 Jun;52(12):1865-1878. [doi:10.1016/S0277-9536(00)00303-8] [Medline: 11352412]
Kessels RP. Patients' memory for medical information. J R Soc Med 2003 May;96(5):219-222 [FREE Full text] [doi:10.1177/014107680309600504] [Medline: 12724430]
McCarthy DM, Waite KR, Curtis LM, Engel KG, Baker DW, Wolf MS. What did the doctor say? Health literacy and recallof medical instructions. Med Care 2012 Apr;50(4):277-282 [FREE Full text] [doi: 10.1097/MLR.0b013e318241e8e1][Medline: 22411440]
Hyatt A, Lipson-Smith R, Gough K, Butow P, Jefford M, Hack TF, et al. Culturally and linguistically diverse oncology
patients' perspectives of consultation audio-recordings and question prompt lists. Psycho-Oncology 2018 Sep;27(9):2180-2188.
[doi: 10.1002/pon.4789] [Medline: 29893041]
Tsulukidze M, Durand M, Barr PJ, Mead T, Elwyn G. Providing recording of clinical consultation to patients-a highly
valued but underutilized intervention: a scoping review. Patient Educ Couns 2014 Jun;95(3):297-304. [doi:10.1016/j.pec.2014.02.007] [Medline: 24630697]
Wolderslund M, Kofoed PE, Holst R, Axboe M, Ammentorp J. Digital audio recordings improve the outcomes of patient
consultations: a randomised cluster trial. Patient Educ Couns 2017 Feb;100(2):242-249. [doi: 10.1016/j.pec.2016.08.029][Medline: 27593087]
van der Meulen N, Jansen J, van Dulmen S, Bensing J, van Weert J. Interventions to improve recall of medical informationin cancer patients: a systematic review of the literature. Psycho-Oncology 2008 Sep;17(9):857-868. [doi: 10.1002/pon.1290][Medline: 18050149]
Pitkethly M, Macgillivray S, Ryan R. Recordings or summaries of consultations for people with cancer. Cochrane Database
Syst Rev 2008 Jul 16(3):CD001539. [doi: 10.1002/14651858.CD001539.pub2] [Medline: 18646075]
Rieger KL, Hack TF, Beaver K, Schofield P. Should consultation recording use be a practice standard? A systematic reviewof the effectiveness and implementation of consultation recordings. Psycho-Oncology 2018 Apr;27(4):1121-1128. [doi:10.1002/pon.4592] [Medline: 29178602]
van Bruinessen IR, Leegwater B, van Dulmen S. When patients take the initiative to audio-record a clinical consultation.
Patient Educ Couns 2017 Aug;100(8):1552-1557. [doi: 10.1016/j.pec.2017.03.001] [Medline: 28302340]
Elwyn G, Barr PJ, Grande SW. Patients recording clinical encounters: a path to empowerment? Assessment by mixed
methods. BMJ Open 2015 Aug 11;5(8):e008566 [FREE Full text] [doi: 10.1136/bmjopen-2015-008566] [Medline: 26264274]
Tsulukidze M, Grande SW, Thompson R, Rudd K, Elwyn G. Patients covertly recording clinical encounters: threat oropportunity? A qualitative analysis of online texts. PLoS One 2015;10(5):e0125824 [FREE Full text] [doi:10.1371/journal.pone.0125824] [Medline: 25933002]
Barr PJ, Bonasia K, Verma K, Dannenberg MD, Yi C, Andrews E, et al. Audio-/videorecording clinic visits for patient's
personal use in the United States: cross-sectional survey. J Med Internet Res 2018 Sep;20(9):e11308 [FREE Full text] [doi:10.2196/11308] [Medline: 30209029]

http://formative.jmir.org/2019/1/e11111/

XSL• FO
RenderX

JMIR Form Res 2019 | vol. 3 | iss. 1 | e11111 | p. 11(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
15.

16.

17.

18.

19.

20.
21.

22.
23.
24.
25.
26.
27.

28.

29.
30.
31.
32.

33.

34.

Lipson-Smith et al

Moloczij N, Krishnasamy M, Butow P, Hack TF, Stafford L, Jefford M, et al. Barriers and facilitators to the implementationof audio-recordings and question prompt lists in cancer care consultations: a qualitative study. Patient Educ Couns 2017
Jun;100(6):1083-1091 [FREE Full text] [doi: 10.1016/j.pec.2017.01.005] [Medline: 28117193]
Lipson-Smith R, Hyatt A, Butow P, Hack TF, Jefford M, Hale S, et al. Are audio recordings the answer? A pilot study ofa communication intervention for non-English speaking patients with cancer. Psycho-Oncology 2016 Oct;25(10):1237-1240.
[doi: 10.1002/pon.4193] [Medline: 27291636]
Hack TF, Pickles T, Bultz BD, Degner LF, Katz A, Davison BJ. Feasibility of an audiotape intervention for patients withcancer: a multicentre, randomised, controlled, pilot study. J Psychosoc Oncol 2000 Oct 12;17(2):1-15. [doi:10.1300/J077v17n02_01]
Hack TF, Whelan T, Olivotto IA, Weir L, Bultz BD, Magwood B, et al. Standardized audiotape versus recorded consultation
to enhance informed consent to a clinical trial in breast oncology. Psycho-Oncology 2007 Apr;16(4):371-376. [doi:10.1002/pon.1070] [Medline: 16906625]
Belkora JK, Loth MK, Chen DF, Chen JY, Volz S, Esserman LJ. Monitoring the implementation of Consultation Planning,
Recording, and Summarizing in a breast care center. Patient Educ Couns 2008 Dec;73(3):536-543 [FREE Full text] [doi:10.1016/j.pec.2008.07.037] [Medline: 18755564]
Darlow S, Wen KY. Development testing of mobile health interventions for cancer patient self-management: a review.
Health Informatics J 2016 Sep;22(3):633-650. [doi: 10.1177/1460458215577994] [Medline: 25916831]
Bate P, Robert G. Experience-based design: from redesigning the system around the patient to co-designing services withthe patient. Qual Saf Health Care 2006 Oct;15(5):307-310 [FREE Full text] [doi: 10.1136/qshc.2005.016527] [Medline:
17074863]
Sanders EB, Stappers PJ. Co-creation and the new landscapes of design. CoDesign 2008 Mar;4(1):5-18. [doi:10.1080/15710880701875068]
Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process 1991 Dec;50(2):179-211. [doi:10.1016/0749-5978(91)90020-T]
Knapp J, Zeratsky J, Kowitz B. Sprint: How To Solve Big Problems And Test New Ideas In Just Five Days. New York:
Simon & Schuster; 2016.
Clegg D, Barker R. Case Method Fast-track: A Rad Approach. Wokingham, England: Addison-Wesley Longman Publishing
Co Inc; 1994.
Zhao J, Freeman B, Li M. Can mobile phone apps influence people's health behavior change? An evidence review. J MedInternet Res 2016 Oct;18(11):e287 [FREE Full text] [doi: 10.2196/jmir.5692] [Medline: 27806926]
Hardeman W, Johnston M, Johnston D, Bonetti D, Wareham N, Kinmonth AL. Application of the theory of planned
behaviour in behaviour change interventions: a systematic review. Psychol Health 2002 Jan;17(2):123-158. [doi:10.1080/08870440290013644a]
Webb TL, Joseph J, Yardley L, Michie S. Using the internet to promote health behavior change: a systematic review andmeta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy. J
Med Internet Res 2010 Feb;12(1):e4 [FREE Full text] [doi: 10.2196/jmir.1376] [Medline: 20164043]
Sniehotta FF, Presseau J, Araújo-Soares V. Time to retire the theory of planned behaviour. Health Psychol Rev 2014;8(1):1-7.
[doi: 10.1080/17437199.2013.869710] [Medline: 25053004]
Ajzen I. The theory of planned behaviour is alive and well, and not ready to retire: a commentary on Sniehotta, Presseau,and Araújo-Soares. Health Psychol Rev 2015;9(2):131-137. [doi: 10.1080/17437199.2014.883474] [Medline: 26209198]
Araújo-Soares V, Hankonen N, Presseau J, Rodrigues A, Sniehotta FF. Developing behavior change interventions for
self-management in chronic illness. European Psychologist 2018 Aug 16:1-19. [doi: 10.1027/1016-9040/a000330]
Noar SM, Zimmerman RS. Health Behavior Theory and cumulative knowledge regarding health behaviors: are we moving
in the right direction? Health Educ Res 2005 Jun;20(3):275-290 [FREE Full text] [doi: 10.1093/her/cyg113] [Medline:
15632099]
Rodrigues AM, Sniehotta FF, Birch-Machin MA, Olivier P, Araújo-Soares V. Systematic and iterative development of asmartphone app to promote sun-protection among holidaymakers: design of a prototype and results of usability andacceptability testing. JMIR Res Protoc 2017 Jun;6(6):e112 [FREE Full text] [doi: 10.2196/resprot.7172] [Medline: 28606892]
Fishbein JN, Nisotel LE, MacDonald JJ, Amoyal PN, Jacobs JM, Flanagan C, et al. Mobile application to promote adherence
to oral chemotherapy and symptom management: a protocol for design and development. JMIR Res Protoc 2017 Apr;6(4):e62[FREE Full text] [doi: 10.2196/resprot.6198] [Medline: 28428158]

Abbreviations
IT: information technology
mHealth: mobile health

http://formative.jmir.org/2019/1/e11111/

XSL• FO
RenderX

JMIR Form Res 2019 | vol. 3 | iss. 1 | e11111 | p. 12(page number not for citation purposes)

JMIR FORMATIVE RESEARCH

Lipson-Smith et al

Edited by G Eysenbach; submitted 26.07.18; peer-reviewed by C Flanagan, A Rodrigues; comments to author 03.09.18; revised
version received 10.10.18; accepted 15.10.18; published 12.03.19
Please cite as:
Lipson-Smith R, White F, White A, Serong L, Cooper G, Price-Bell G, Hyatt A
Co-Design of a Consultation Audio-Recording Mobile App for People With Cancer: The SecondEars App
JMIR Form Res 2019;3(1):e11111
URL: http://formative.jmir.org/2019/1/e11111/
doi: 10.2196/11111
PMID: 30860487©Ruby Lipson-Smith, Fiona White, Alan White, Lesley Serong, Guy Cooper, Georgia Price-Bell, Amelia Hyatt. Originallypublished in JMIR Formative Research (http://formative.jmir.org), 12.03.2019. This is an open-access article distributed under
the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, isproperly cited. The complete bibliographic information, a link to the original publication on http://formative.jmir.org, as well as
this copyright and license information must be included.

http://formative.jmir.org/2019/1/e11111/

XSL• FO
RenderX

JMIR Form Res 2019 | vol. 3 | iss. 1 | e11111 | p. 13(page number not for citation purposes)