Evaluation of a Telehealth Website System for Patients with Total Hip Arthroplasty

Provider utilizing telehealth system

Limitations of time and staff availability make it difficult to offer sufficient support to patients within three months after undergoing total hip arthroplasty (THA) in Japan. Older patients undergoing THA often face difficulties in various facets of their daily lives, including the need for home-based support while they recover from surgery. Therefore, we conducted a preliminary investigation about the difficulty in everyday life and the necessary medical support required for these patients. According to the results, we have designed desirable content and functions and have implemented each of them in a supportive system. Our constructed THA Telehealth Website system consists of five content areas: “Daily life information,” “For family members,” “Forum,” “Rehabilitation facility,” and “Resting spots and bathrooms”.  The purpose of this article is to report on the evaluation of the newest version of the THA Telehealth Website System by THA patients and nurses where individual content areas and functions are integrated with one another. Tablets were given to participants (25 THA patients and 5 discharge nurses) for two weeks with unrestricted use. Participants then answered a questionnaire with questions on their predicted use of the system in the three- month postoperative period. The Web Usability Evaluation Scale (WUES) comprised of 21 questions was used for system evaluation. The results of the system evaluation were positive overall for both patients and nurses in all seven WUES evaluation categories. We achieved a good usability with scores of 3.5-4.5 out of 5 for these categories and confirmed the effectiveness of our THA Telehealth Website System via a pre-test for predicting system use by THA patients and discharge nurses. It is still necessary to improve the manual for older adult patients who are unaccustomed to accessing the internet or a tablet and to enhance content for male patients to achieve on-site trial use for the target group of THA postoperative patients.


The proportion of the Japanese population aged 65 years or more has increased with each passing year, from 25.1% in 2013 to 27.3% in 2016, and this figure is expected to rise to 31.2% by 2030 (Cabinet Office, Government of Japan Official Website, 2017). As patients continue to age, disease patterns are changing and are marked by an increase in chronic degenerative diseases. Among these, circulatory diseases have the highest prevalence among older adults, followed by motor diseases. The signs of aging in the motor system are characterized by deterioration of the bones, cartilage, muscles, tendons and ligaments, and the joints can be affected by osteoarthritis (OA). In Japan, OA prevalence as diagnosed by radiography is 1.0%–4.3%, occurring in 1.2–5.1 million people (The Japanese Orthopaedic Association & Japanese Hip Society, 2016). One treatment for hip osteoarthrosis is total hip arthroplasty (THA), which is widely performed ranging from approximately 80,000 operations in Japan (The Japanese Society for Replacement Arthroplasty, 2017), and in the United Kingdom (UK) (National Joint Registry, 2017), and 300,000 in the United States (American Joint Replacement Registry, 2017) in 2016. Furthermore, the predicted number of THA procedures will be approximately 120,000 in Japan by 2030 (NexMed International, 2011), 96,000 in the UK by 2035 (Culliford, et al., 2015), and 572,000 in the U.S. by 2030 (Kurtz, Ong, Lau, & Halpern, 2007). As such, these numbers are predicted to increase globally according to the forecasted aging of each country’s population.

Although THA has many benefits, such as eliminating hip joint pain, improving walking ability because of increased hip range of motion, and expanding range of activities of daily living, it has disadvantages such as dislocations, infections, friction and loosening because of the material and structure of the prosthetic joint (Takayama & Fukumoto, 2008). In particular, the Japanese lifestyle involves kneeling and sitting on the floor on the legs (seiza), as well as sleeping on the floor on a futon, and these practices increase the risks of hip dislocation after THA. Therefore, it is necessary for THA patients to make modifications to accommodate their postoperative lifestyles, which can be a difficult process (Hashiya, Takeshita, Kajimura, & Azuma, 2013). However, although improvements in medical techniques and health care reforms have facilitated a shorter length of hospital stay, this results in patients not having time to acquire all the necessary behavioral skills and knowledge during the hospitalization period that they will need for daily living after discharge from hospital. Furthermore, in the present Japanese health care environment, post-discharge support systems have not been fully developed, and follow-up to support patients is insufficient. Accordingly, a new system is needed for continued follow-up after discharge to support patients in their daily lives as much as possible.

Patients do not receive sufficient support by going to outpatient visits alone because of limitations of time and staff availability. Patients who undergo THA often face difficulties in various aspects of their daily lives and sometimes require home-based support while recovering from surgery. Telehealth is a potentially effective means of making such follow-up possible. Telehealth refers to distant consultations and guidance using remote monitoring, self-management by telephone communication, visiting care providers, and other tools for patient use at home. One of the goals of telehealth is teaching patients self-management skills to improve their quality of life (Stowe & Harding, 2010). Some of the known homecare systems using telehealth are for patients with chronic diseases such as diabetes (Bonoto, et al., 2017; Iijaz, Brodnik, Zrimec, & Cukjati, 2017), chronic obstructive pulmonary disease (Bernocchi, et al., 2017; Maccabe, Mccann, & Brady, 2017), and cardiovascular diseases (Chow, et al., 2015; Noergaard, et al., 2017), and the effectiveness of this approach has been demonstrated through various studies. However, there have been few initiatives to implement telehealth for patients undergoing THA. One Canadian study examined web-based follow-up for patients following THA or total knee arthroplasty (Marsh, Bryant, & Macdonald, 2014). In Japan, there have been previous attempts accessing the online platform THA CareNet, which collectively proposed self-monitoring, assessment tools using web cameras, and education and support tools by experts (Satoh, 2012). However, THA CareNet is an expert-centered system, and there was little emphasis on its utility as a patient-centered remote system for providing continued daily support following discharge.

Therefore, we focused on creating a remote THA Telehealth Website System to allow patients to continue receiving support after discharge that is tailored to their individual physical or lifestyle conditions. Initially, we conducted a preliminary investigation about difficulty in everyday life and necessary medical support for THA patients (Hashiya, et al., 2013, Hashiya, Kajimura, Takeshita, & Azuma, 2013). According to the results, we designed desirable content and functions and implemented each of them in a system step by step (Hashiya, et al., 2015; Hashiya, Azuma, Kajimura, & Nishimura, 2017). Specifically, it entailed pertinent information that patients could retrieve themselves as they encountered the need in various aspects of their daily lives, including content to improve understanding of and cooperation with family members, tools to enable both patient-to-patient and patient-to-expert communication, and information and various resources that patients can use to readjust their lives in their homes and communities.

The purpose of this article is to report on the evaluation of the newest version of the THA Telehealth Website System by THA patients and nurses, where individual content and functions are integrated with one another to provide guidance in the hospital setting and to investigate its utility for future implementation.

Integrated THA Telehealth Website System

Intended Users

The risks of hip dislocation are high in the three months following THA because of insufficient tension of the soft tissues such as the ligaments around the hip joint (Cobb, Morrey, & Ilstrup, 1996); therefore, there is a supplementary need to provide support during this period. Accordingly, this system was created with patients in the three months following their first THA as the intended users.

The lifespan of a prosthetic joint is generally 15–20 years; therefore, patients aged 60 years or more are the ideal candidates for THA for avoiding revision surgery. Hence, older adults make up the majority of THA patients. In 2016, the rate of internet usage among Japanese older adults in their 60s, 70s, and 80s was 70.4%, 42.8%, and 14.5%, respectively. Those aged 60 years or more access the internet on computers (32%), cellular phones (17.2%), smartphones (13.2%), and tablet terminals (6.8%) (Ministry of Internal Affairs and Communications, 2016). Thus, we can predict that the majority of THA patients are beginners in operating information and communication technology devices.

Developmental Environment of the THA Telehealth Website System

We used a responsive web design for this system that can be used on any computer, smartphone or tablet. The development environment consisted of a Debian Wheezy 8.0 Server Operating System, Apache 2.4 web server, MySQL (ver. 5.6) for data storage and management, Google Maps application programming interface (API) for map-specific content, and was programmed using HTML5, CSS3, and PHP 7.0.

Content Composition

Figure 1 displays the site map for all of the system contents and functions developed in this study. We broadly grouped content under the following five items: “Daily life information,” “For family members,” “Forum,” “Rehabilitation facility,” and “Resting spots and bathrooms,” as shown in the top screen in Figure 2. Hereafter, we will describe the content and functions of each topic.

Figure 1. Map of the content and functions of the THA Telehealth Website system

Figure 2. Top screen of the THA Telehealth Website System
(Left: Original screen, Right: English description of original screen)

Information for Daily Living

Under “Daily life information,” there are five subitems on the topics as shown in Figure 1. “How to spend daily life” is composed of 14 specific items in Figure 3.

“Fall prevention” is divided into two items of

  • “How to prevent falls while out” and
  • “How to prevent falls at home,”

 “Preventing and responding to infection” is composed of the following six items:

  • “Surgical wound infection,”
  • “Preventing cold and flu,”
  • “Preventing norovirus,”
  • “Foot injury,”
  • “Preventing caries,” and
  • “Preventing athlete’s foot.”

“About rehabilitation” consists of two items:

  • “Voluntary exercise” and
  • “About sports”

 “Social resources” consists of the following three items:

  • “Certificate of Physical disability,”
  • Nursing Insurance,” and
  • “Medical rehabilitation services.”

Figure 3.  Selection buttons for specific items under subitem [How to Spend Daily life] under major item “Daily Life information”
(Left: Original screen, Right: Corresponding English description)

Each content item was created on the basis of experiential knowledge gleaned from the literature or from physicians, nurses and physiotherapists. We used text, a total of 121 images and eight videos to display information on postoperatively required lifestyle changes regarding behaviors, movements and postures taken in daily life. Correct examples, incorrect examples, and precautions are displayed, as well as the precise instructions and illustrations for making these changes, e.g., the scroll screen example for “How to sit on your legs” under “How to spend daily life”, as displayed in Figure 4, uses text, images and videos to explain the steps for sitting on the legs.

Figure 4. Example: Scroll screen for specific item “How to sit on your legs” under Major item “Daily life information”---subitem [How to spend daily life]
(Left: Original screen, Right: Corresponding English instructions)

For Family Members

The majority of THA patients are women; hence, they are often the ones in the family who manage household chores and do the cooking. Postures requiring hip flexion are often taken during movements involved in household chores or shopping; thus, women are more likely to have dislocations because of taking contraindicated postures. Therefore, three subitems,

  • “What is THA?”
  • “Points to notice after surgery” and
  • “About family cooperation”

are located under “For family members” to educate family members on THA. As shown in Figure 5, “What is THA?” explains the indications for the surgery and summarizes the benefits and postoperative complications of the surgery. Postoperative complications such as dislocation and bacterial infections are discussed. Furthermore, the section on dislocations includes a link to Major item “Daily life information” — subitem “How to spend daily life”— Specific item “Positions prone to dislocation”, and the section on bacterial infections includes a link to Major item “How to spend daily life”─ subitem “Preventing and responding to infection”— specific items “Preventing cold and flu” and “Preventing norovirus”.

The section “Points to notice after surgery” explains what kind of daily postures and movements require caution, with a link available on the corresponding point to notice Major item “Daily life information”─ subitem “How to spend daily life”.

“About family cooperation” explains what type of cooperation or assistance is required to prevent complications, while giving/showing examples of movements in daily life. Therefore, links to Major item “Daily life information”— subitem “Preventing and responding to infection” ─specific items “Preventing cold and flu,” “Preventing noro virus” and “Preventing athlete’s foot” are highlighted as well.

Figure 5.Example: Scroll screen for subitem “What is THA” under major item “For family members”
(Left: Original screen, Right: Corresponding English description)


The “Forum” was established as a communication tool and is not only intended for information exchange between patients suffering from the same disease but also provides a chance for mutual help from people living through the same problems and experiences. Furthermore, medical staff can also participate in the discussions, allowing patients to obtain expert responses as well.

Older adults are generally more likely to forget their user IDs or passwords; therefore, user identification will be done through registering the hash value of the image data to the webserver so that the server will perform the hash calculation to the pre-entered image data for matching at the time of user identification. As a concrete way for users, each user can log into the Forum by merely dragging and dropping the image, which has been created and automatically saved at the same time as user registration. This allows only users who are approved by the system administrator to participate in the forums.

Patients undergoing THA are required to make changes in their preoperative lifestyles. Therefore, a wide variety of questions and problems are expected to arise, the data for which will be displayed in a thread format to allow subjects to be divided by topic. Furthermore, the content of new and past questions and problem consultations including a response form are on one page in a batch display to allow users to easily offer their opinions and other responses to questions or problems posed by other users, as displayed in Figure 6.

Figure 6. Example of a batch display by theme on “Forum”
(Left: Original screen, Right: Corresponding English description)

Information on Rehabilitation Facility

Voluntary exercises to be done at home such as muscle strengthening exercises or precautions to take before starting a sport are explained under Major item “Daily life information”—subitem “About rehabilitation”. In addition, patients who undergo THA are anxious about one-on-one rehabilitation and often seek information on facilities that offer rehabilitation services (Hashiya, et al., 2013). Thus, this system provides information on facilities offering rehabilitation services to THA patients. Data on facilities are inputted from the administrator screen by the authors themselves. An example of a search result is shown in Figure 7 “Example of a Rehabilitation facility search result.” A facility search can either be done according to the user’s current location or by entering the information. The pins on the map shows the locations of the rehabilitation facilities, and information about a facility can be displayed by selecting the corresponding pin. Facility information includes the name of the facility, address, hours and days of operation, telephone number, access information, whether individual patients can get services at the facility, and whether registration must be made via the regional communication office of the hospital for inpatient or outpatient care.

Figure 7. Example of a “Rehabilitation facility” search result
(Left: Original screen, Right: Corresponding English description)

Information on Resting Spots and Bathrooms

Patients who have undergone a THA are encouraged to walk to maintain and improve their muscle strength and overall physical strength; however, walking for long hours puts a strain on the prosthetic joint and may trigger a complication, so adequate rest is required. With regard to bathrooms, a Japanese-style (squat) toilet requires the user to take a position that involves hyperflexion of the hip joint, thus using a Western toilet is recommended. However, some public toilets only have a Japanese-style toilet, thus making patients anxious about leaving their house.

Providing information on where to take breaks or the locations of Western-style toilets can relieve patients of some of these anxieties, which is the goal of this menu item “Resting spots and bathrooms.” Locations are entered by the authors and students of their affiliated universities. Figure 8 displays a sample search result obtained through “Resting spots and bathrooms.” A search can be done either from the user’s current location or by inputting the information. The pin on the map shows the locations of the resting spots and bathrooms, selecting the corresponding pin will display the name, pictures, number of available chairs for resting spots, and/or number of Western toilets, multipurpose stalls, and wheelchair stalls that are available for bathrooms.

Figure 8. Example of a search result on “Resting spots and bathrooms”
(Left: Original screen, Right: Corresponding English description)

Design Features for Older Adults

Older adults are often relatively more limited in their cognitive abilities to process tasks requiring information stored in their short-term memories (Osaka, Logie, & D’Esposit, 2007; Otsuka & Miyatani, 2016). Therefore, older individuals may be more likely to get lost or confused with unpredictable website elements including popups or multi-staged designs such as a pull-down menu. Therefore, the menus are designed in such a way that everything is already visible on the screen and can be operated by simply tapping a button.

As well, older adults often have decreased visual acuity and weakened motor skills and finger muscle strength, which decreases their ability to perform tasks requiring precision. A text button may not necessarily convey the correct affordance to older adults who may not recognize that it is a button (De Barros, Leitao, & Ribeiro, 2014; Wildenbos, Jaspers, Schijven, & Dusseljee-Peute, 2019). Therefore, buttons on the website use large image icons accompanied by a text label to increase affordance as shown in Figure 3.

Some of the characteristics of an older adult’s operation include long-pressing buttons on the touch panel (Sugimoto & Saku, 2012). The liquid crystal in a normal touch screen device uses electrical capacitance, which means that it detects very small electric currents from the body the moment the finger touches the display. The current passes less easily when the finger is dry, making the response less sensitive. Because aged skin is dryer (Brooks, Cowdell, Ersser, & Gardiner, 2017), touch screen devices respond less sensitively to older people’s fingers, which is why they tend to long-press a button selection more often. Furthermore, older individuals tend to press buttons harder or repeated times without feedback to let them know that the button has been pushed (Sugimoto & Saku, 2012; Kuerbis, Mulliken, Muench, Moore, & Gardner, 2017). The functions assigned to long-pressing on a smartphone or a tablet are normally the same as right-clicking on a mouse, so this makes the user prone to experiencing malfunction. To solve this problem, our system is set up so that a long-press produces the same responses as a normal tap.

Older individuals are also more prone to getting lost and losing track of which page they are on because they have more difficulty remembering the page or screen history when too many screen transitions have been made (Shart, Hernandez, Czaja & Pirolli, 2008; Hayashi, Hashimoto, Saito & Asano, 2011; Kuerbis, et al., 2017). To assist users, a list showing where the user is currently located (breadcrumbs) is available in the upper left corner of each page as shown in Figure 9. Furthermore, a button in the form of an icon image is placed at the bottom of the screen to allow the user to easily go “Back” to the preceding page or to move to the “Next” page.

Figure 9. Example of the transfer button (screen bottom) under “How to sit on your legs” to go “back” or “forward” and the list of the current location (breadcrumbs)
(Left: Original screen, Right: Corresponding English description)

Data entry on a tablet is normally done using a keypad; however, older patients typically have difficulty using a keypad or accomplishing tasks that require precision as a result of declining vision and fine motor abilities, as mentioned earlier. Therefore, a voice recognition system installed on the tablet enables those individuals with such difficulties to utilize features such as “Forum,” “Rehabilitation facility,” or “Resting spots and bathrooms” without having to input each item on a keypad,

System Evaluation

Subjects and Methods

Participants included 25 patients who underwent THA and were followed up at the outpatient clinic and five nurses working at the hospital who were responsible for discharge planning for THA patients. They used a tablet terminal (iPad Mini 2) to access the system. The methods of operating the tablet and the system were explained to the participants, and tablets were loaned to them for two weeks with instructions to use the system freely. Next, we provided the participants with a questionnaire survey assuming the target user was a postoperative patient within three months after their surgery.

System evaluation was conducted on the basis of the Web Usability Evaluation Scale (WUES) (Nakagawa, Suda, Zenpo, & Matsumoto, 2001). WUES is a usability scale developed through the joint research of Fujitsu Limited and Iid, Inc., composed of the 21 items displayed in Table 1. Respondents rated how much they agreed with each statement on a Likert scale with a maximum of five points per statement: “Strongly agree (5 points),” “Agree (4 points),” “Neither agree nor disagree (3 points),” “Somewhat disagree (2 points),” and “Strongly disagree (1 point).” Each of the questionnaire statements were divided into the seven corresponding evaluation categories of “Appeal,” “Helpfulness,” “Reliability,” “Operability,” “Navigability,” “Visibility,” and “Reactivity.”

Table 1: Questionnaire items of the Web Usability Evaluation Scale (WUES)

Demographic Items on the nurses’ basic characteristics included sex, age, years of experience as a nurse, years of employment in the orthopedics department, whether they possessed a mobile device, and the number of months they have been using it. Items of patient basic characteristics included sex, age, disease name, number of postoperative months, whether they possessed a mobile device, the number of months they have been using it, and the sources they used other than the hospital to obtain THA-related information.

Methods of Analysis

The mean score per evaluation category was determined for each of the three questionnaire items and compared between patients and nurses. The reverse scoring items, statements 5, 6, 17, 18, 20, and 21, were calculated by subtracting the score from 6. A normal distribution could not be expected for the results, so the Mann–Whitney U-test was used for statistical analysis. Patients were divided on the basis of those aged less than 60 years and 60 or more years, men and women, those who possessed a mobile device and those who did not, and whether they obtained THA-related information (hereafter, “Information source”) from the internet or somewhere other than the internet. Mean scores were compared by group for each WUES evaluation category. Items for which a normal distribution could not be expected by a test of normality were analyzed using the Mann–Whitney U-test. Furthermore, Spearman correlation coefficient was calculated between the items of age, sex, whether they possessed a mobile device, information source, and WUES evaluation category. IBM SPSS statistics 24 was used for analysis, and p-values <0.05 were considered significant for all tests.

Ethical Considerations

This study was approved by the Ethics Committee of the Graduate School of Applied Informatics of the University of Hyogo. Written informed consent was obtained from participants after they were told about the voluntary nature of study participation, that there were no penalties for refusing or withdrawing from participation, and how to discontinue participation. Furthermore, they were informed that the data collected in this study would not be used for any purpose other than research, and that personal information would be handled with strict adherence to confidentiality.

Results of the System Evaluation

Basic Characteristics

The mean age of the five nurses was 33.8 (SD = 5.3) years, with mean 10.6 years (SD = 4.8) of experience as a nurse and mean 5.9 (SD = 2.6) years of experience as an orthopedic nurse. All nurses had experience using a mobile device for a mean of 30.4 (SD = 19.4) months.

The age distribution of the 25 patients is displayed in Figure 10.

Figure 10. Age distribution of participants (n=25); x-axis shows ages; y-axis shows counts

Most patients were in their 70s (eight patients), followed by those in their 50s or 60s (six patients each), with a mean age of 65.9 (SD = 14.3) years. In total, there were six men and 19 women with diseases including hip OA (21), femur head osteonecrosis (1), acetabular dysplasia (1), femoral neck fracture (1), and hip dislocation (1). The distribution of the number of postoperative months passed since the surgery is displayed in Figure 11. Mean months since the surgery was 63.4  months, with 12–60 months being the most common number (12). Overall, 13 patients possessed a mobile device, 12 patients did not, and mean duration of mobile device use among those who possessed a mobile device was 40.4 months. Most patients relied on the internet (8), followed by friends (2) and television (1) to obtain information related to THA in addition to information they received from the hospital, while the remaining 14 patients only received information from the hospital.

Figure 11. Distribution of postoperative months (patients) (n=25); x-axis shows months; y-axis shows counts

Regarding participant selection, some doctors in charge of the patients had concerns about applying the new system under development to immediate THA patients within three months postoperatively in isolation from the existing support of hospital. In this paper, therefore, prior to the system evaluation by the target group of THA patients, we sought patients who were well past THA surgery as participants and got answers for the system evaluation from them as they looked back on the time when they had been within the three months postoperative period.

Mean Scores by WUES Evaluation Category: Comparison Between Nurses and Patients

Mean scores for each WUES evaluation category for nurses and patients are shown in Table 2, respectively. They are also represented in a radar chart as shown in Figure 12. Mean scores were greater than 3 for all evaluation categories for both nurses and patients, demonstrating positive results overall. Furthermore, there were no significant differences between nurses and patients for each WUES evaluation category.

Table 2. Mean WUES Evaluation scores by category

Figure 12. Mean scores by WUES evaluation category: Patients and nurses

However, there was some divergence between nurses and patients in their results for “Operability” (U = 35.0, z = -1.554, p = .120, n.s) and “Reactivity” (U = 37, z = -1.434,  p = .152, n.s) with patients having somewhat lower scores. The frequency distribution of the 30 participants’ scores for “Operability” and “Reactivity” are shown in Figures 13 and 14, respectively. Although the scores are between 4.0 and 5.0 points for nurses, there is some spread for patients’ scores, which were between 2.0 and 5.0 points.

Figure 13. Frequency distribution for “Opetability” (Nurses and patients); x-axis shows points; y-axis shows counts

Figure 14. Frequency distribution for “Reactivity” (Nurses and patients); x-axis shows points; y-axis shows counts

Mean Scores by WUES Evaluation Category: Comparison by Patients’ Basic Characteristics

A comparison of scores by WUES evaluation category by age (<60 years vs ≥60 years) is shown in Table 3, by sex in Table 4, by mobile device ownership in Table 5, and by information source (internet vs other) in Table 6.

Table 3. Mean scores for WUES Evaluation categories by age (p-values)

Table 4. Mean scores for WUES Evaluation categories by sex (p-values)

Table 5. Mean scores for WUES Evaluation categories by mobile device ownership (p-values)

A comparison by information source (Table 6) revealed that results for “Helpfulness” (U = 28.5, z = -2.337, p = .019) and “Navigability” (U = 39.5, z = -2.089, p = .049) were significantly higher for internet users. Furthermore, though not statistically significant, patients aged 60 years or more had lower scores for “Helpfulness” (U = 47.5, z = -1.549, p = .121, n.s) as shown in the comparison by age (Table 3), and comparison by sex (Table 4) revealed that scores for “Reliability” (U = 32.5, z = -1.622, p = .105, n.s) were higher for women. Finally, the comparison by ownership of mobile devices (Table 5) showed that participants who owned a mobile device had higher scores for “Helpfulness” (U = 49.5, z = -1.575, p = .115, n.s) and “Operability” (U = 47, z = -1.711, p = .087, n.s).

Table 6. Mean scores for WUES Evaluation categories by information source (p-values)

Correlations Between Mean Scores by WUES Evaluation Categories and Patients’ Basic Characteristics

Table 7 displays correlations between patient sex, age, ownership of mobile device, and information source, and mean scores for the WUES evaluation categories. There were significant negative correlations between age and mobile device ownership (rs= −.683, p = .000) and age and information source (rs= −.613, p = .001). Furthermore, there was a significant positive correlation between information source and mobile device ownership (rs= .659, p = .000) and between information source and scores for “Helpfulness” (rs= .477, p = .018).

Table 7. Correlations between patients’ basic characteristics and scores by WUES evaluation category


This study described the development of the THA Telehealth Website System, a system intended to provide web-based assistance to patients in the first three postoperative months after they underwent their first THA and conducted a system evaluation with patients who had previously experienced THA and their discharge nurses. The results of the system evaluation were positive overall for both patients and nurses in all seven WUES evaluation categories as shown in Table 2 and Figure 12, with mean scores of 3.5–4.5 for both groups.

Furthermore, there were no significant differences between nurses and patients when comparing their scores for the WUES evaluation categories, suggesting that the patient evaluations were no different from those of nurses, who are experts clinically, and that this system achieved a certain level of usability for patients as well. As mentioned above, although the difference was not significant, patients usually scored lower for “Operability” and “Reactivity” than nurses, but as shown in Figures 13 and 14, this was attributed to the greater spread in patient scores. Some of the possible reasons for this gap could be the fact that all of the nurses owned a mobile device, whereas approximately half of the patients did not and were unaccustomed to operating mobile devices in addition to having drier skin, resulting in lower reactivity of the touchscreen devices.

Comparison by information source in Table 7 revealed that scores given for “Helpfulness” and “Navigability” were significantly higher for internet users, and somewhat higher scores were given for “Helpfulness” and “Operability” by owners of mobile devices. Individuals who are accustomed to gathering information on the internet have related knowledge and skills, so these results seemed reasonable. The same trends are also supported by the significant positive correlations found between information source and mobile device ownership and between information source and “Helpfulness,” as shown in Table 7.

Results in Table 3 showed that patients aged 60 years or more had somewhat lower scores for “Helpfulness,” and in Table 7 there were significant negative correlations between age and mobile device ownership and between age and information source, suggesting that older individuals have fewer incentives to use mobile devices or the internet, and take more time because they are unable to operate them smoothly. Although we explained the system operation methods with a manual at the beginning of the study, it is understandable for it to be burdensome for older patients to go back to the manual for help, especially if they have already lost their motivation. One of the measures to overcome this point may be to minimize the sentences used in the manual and to replace them with abundant images that give a more intuitive understanding, and to give more on-site support until the patient has become accustomed to operating the system.

A comparison of WUES evaluation categories by sex resulted in somewhat higher scores for women for “Reliability”. We can speculate that this was because of the fact that the item “For family members” focused more on household chores and on cooperation that the family can provide to prevent dislocations during these activities, and that all the models used in the images and videos were women because the majority of THA patients are indeed women. We should take into consideration that around 15% patients who receive THA are men (The Japanese Orthopaedic Association & Japanese Hip Society, 2016) and increase the amount of information more pertinent for male patients, such as returning to work or aspects of life in the community.

Conclusions and Future Objectives

We evaluated the THA Telehealth Website System geared toward THA patients during their three postoperative months. A pre-test on THA patients and nurses responsible for their discharge planning care demonstrated that a good level of usability was achieved, suggesting its effectiveness as a web-based post-discharge support system. Going forward, modifications to the manual for older adults who are unaccustomed to accessing the internet or tablet will be made and content for male patients will be increased. In addition, we will introduce a more recent tool for usability evaluation focused on telehealth provision such as the Telehealth Usability Questionnaire (Parmanto, Lewis, Graham, & Bertolet, 2016), in addition to the WUES. Finally, an on-site trial for the target group of THA patients who are within the three months postoperative period will be conducted. We also plan to further validate the effectiveness of this system through evaluating levels of satisfaction with the system and quality of life, for instance, on decreasing readmission rates for dislocation.


This work was supported by JSSPS KAKENHI Grant Numbers JP24792430, JP15K1158317.

The views and opinions expressed in this blog or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.

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Author Bios:
Akane Hashiya, MAI, RN, is an associate professor at Osaka University of Education. Her research focus is the support of patients using telenursing. She is in a doctoral course at the Graduate School of Applied Informatics, University of Hyogo.

Masumi Azuma, RN, PhD, is a professor at Kobe Women's University, Japan. She received a PhD from the Division of Nursing of University of Hyogo in 2011. She is interested in nursing informatics, telenursing, and chronic care nursing.

Ayako Kajimura, MAI, RN, is in a doctoral course at the Graduate School of Applied Informatics, University of Hyogo. Her specialty is nursing informatics and she is currently working on a study on the usability of an electronic chart.

Haruhiko Nishimura, PhD, completed the doctoral program at Kobe University, 
and received the PhD degree in 1985. He is a professor in the Graduate School of Applied Informatics, University of Hyogo. His research interests are intelligent systems, healthcare, and high confidence sciences. He is a member of the IEEE, IEICE, IPSJ, ISCIE, JNNS and others and was awarded ISCIE paper prize in 2001 and JSKE paper prize in 2010.