FEATURE ARTICLE
Avoiding Obsolescence in Mobile Health
Experiences in Designing a Mobile Support System for Complicated
Documentation at Long-term Care Facilities
Ming-Hsiang Tu, MS, RN, Polun Chang, PhD, Ying-Li Lee, MS, RN
This study examined staff perceptions of planned obsoles-
cence during a transition from old to new handheld devices
for long-term mobile healthcare. Questionnaires based on
the technology acceptance model were used to evaluate per-
ceived ease of use and usefulness. This study recruited 120
staff from 26 long-term care facilities who used the old de-
vice and 86 staff from nine of the 26 original facilities who
used the new device. Although the new devices with ad-
vanced features scored significantly higher in acceptance
ratings, users still expressed high acceptance of, satisfac-
tion with, and willingness to use the old device, which fea-
tured an effective and carefully designed user interface.
Usability design plays an essential role in preventing
the obsolescence of mobile handheld technology.
KEY WORDS: Handheld devices, Mobile health, Planned
obsolescence, Usability, User interface
obile health is a division of electronic healthcare
M that involves the use of mobile and wireless devices,
such as computers, mobile phones, personal digital
assistants (PDAs), communication satellites, and patient moni-
tors, to improve health service delivery, research, and out-
comes.1,2 Mobile health positively affects the healthcare
system by improving access, quality, and cost.3 Mobile de-
vices have repeatedly been found to improve completeness,
accuracy, and timeliness of patient documentation, leading
to superior care through such improvements as increased
medication safety.4–7
Mobile health has three major components: mobile tech-
nology, handheld devices, and mobile operating systems.
Mobile technology is the primary force driving promotion
Author Affiliations: Institute of Biomedical Informatics, National Yang-Ming University, Taipei,
Taiwan, ROC.
This study was supported by a grant from the Ministry of Science and Technology in Taiwan (ROC).
The authors have disclosed that they have no significant relationships with, or financial interest
in, any commercial companies pertaining to this article.
Corresponding author: Polun Chang, PhD, Institute of Biomedical Informatics, National Yang-
Ming University, Room 520, Library and Information Bldg, No 155, Sec 2, Li-Nong St, Beitou
District, Taipei City 11221, Taiwan, ROC (polun@ym.edu.tw; ntuh.katherine@gmail.com).
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/CIN.0000000000000460
Volume 36 | Number 10
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
and integration of mobile communication and information
technology with features such as high mobility and porta-
bility. Mobile devices can be divided into three categories:
voice-centric cellular phones, data-centric devices (eg, PDAs
and tablets), and intelligent devices (eg, smartphones and
PDA phones) that are both data- and voice-centric.8 The
most commonly used operating systems are Android, iOS,
Windows, and BlackBerry. Among these four systems, only
Android is an open-source system. According to a 2016
Gartner survey, Android owned 86.2% of the global mo-
bile device market share (followed by iOS at 12.9%).9
Like all modern technologies, mobile health has a unique
product life cycle (PLC). Constant innovation and rapid
technological advancement lead to substantially shortened
PLCs in the mobile device market.10 From the perspective
of user acceptance, the technology hype cycle has become
a crucial reference for the PLCs of new technologies.11
The continual appearance of new high-tech products
has intensified market competition and shortened PLCs to
the extent that new products rapidly become obsolete. This
phenomenon is not necessarily technological obsolescence;
it is likely planned obsolescence. Packard12 proposed that
products can become obsolete in three ways. First is the ob-
solescence of function, which means that new products out-
perform existing products. Second is the obsolescence of
quality, which implies that products become obsolete be-
cause of defects. For example, the use of the iPhone 4 was
gradually discontinued through a lack of software updates,
and production of the Samsung Note 7 ceased because of
battery problems. Third is the obsolescence of desirability
(also referred to as psychological obsolescence), which sug-
gests that properly functioning products become obsolete
when their users are attracted to other or newer products.
Planned obsolescence is a policy of artificially limiting the
useful lifetime of a product. It is often used to sell “new
and improved” products.13 Promoting the improved func-
tions and attractive appearance of newer products and
discontinuing support for older products are strategies of
planned obsolescence.
Mobile health is expected to play a dominant role in
future healthcare. This article reports staff experiences with
CIN: Computers, Informatics, Nursing 501
FEATURE ARTICLE
technological obsolescence and introduces new mobile health
technology in a long-term care setting.
METHODS
This study used two generations of handheld devices (3.9-in
Palm OS device, HD1; 6-in Android device, HD2) in long-
term care for complex comprehensive geriatric assessment.14
The subjects were healthcare staff from participating long-term
care facilities. The technology acceptance model (TAM) was
used to design a questionnaire to evaluate subjects’ perceived
ease of use and usefulness, and willingness to use the devices.
DESIGN
The 3 + 1 hierarchical grid screen design principles14 were
used to design complex documentation using the compre-
hensive geriatric assessment tool in nursing homes. The prin-
ciples consist of three main layers, two for categorical purposes
and one for assessment questions. The first layer contained
categories of questions, the secondary layer contained sub-
categories, and the third layer contained actual questions.
The first-generation system, the 3.9-in Palm-OS-based
handheld device called the PalmOS device15 (HD1), was
used in 2009. In July 2011, a new 6-in Android-based hand-
held device called the Mio16 (HD2) was planned to be used
as a replacement. The same program applications and inter-
face design principles were used for both HD1 and HD2.
HD2 had preferable features in almost all aspects, such
as a larger font size, a higher resolution, a larger button
size, a superior operating system, a speedier processor,
smoother screen navigation, and programmable hotkeys
for an easy one-handed operation. HD1 had a resolution
of 320  480 pixels and a 3.9-in screen display (largest
on the market at the time), a weight of 155 g, a Palm OS
5.4.9 operating system, a 312-MHz processor, 5  10-mm
screen buttons, and stylus operation. Although the font size
was only 3  3 mm, it was easy to read. HD2, introduced
in 2012, had a 6-in multitouch screen, a 800  480 resolu-
tion, a 320-g weight, an Android 2.2 operating system,
1-GHz processor speed, and 15  20-mm screen buttons.
The HD2 font size was 8  8 mm with a shorter reaction
time. It was also the first tablet specifically designed for the
use of healthcare staff, including features such as disinfec-
tion, waterproofing, and a crushproof design.
PARTICIPANTS
The participants in this study were 120 healthcare staff from 26
independent long-term care facilities, at each of which 49 to
400 residents resided, recruited in August 2009, and 86 health-
care staff from nine of the 26 facilities, recruited in September
2011. All participants were female, trained in nursing, aged 40
to 49 years, and frequent computer users, with 5 to 10 years of
work experience and college education.
502 CIN: Computers, Informatics, Nursing
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
TRAINING PROCESS AND DATA COLLECTION
All participants in this study attended the same two-session
training. At the class-based first session (4 hours), they were
trained for (1) the paper-based Chinese version of the com-
prehensive geriatric assessment with the interRAI MDS-NH
2.1 nursing home assessment tool,14,17 which comprised
25 pages composed of 19 sections, including demographic
information, intake and initial history, cognition, commu-
nication, and vision; (2) HD1 and HD2 with three practice
scenarios; and (3) the method required to complete the TAM
evaluation questionnaire.18,19 At the practice-based second
session, the participants took the devices back to their own
facilities to use for 2 months and completed evaluations for
500 residents. The participants spent an average of 1.5 hours
to evaluate four residents. During this period, an experi-
enced trainer was dispatched to each institution to provide
on-site training and answer questions. All participants com-
pleted the TAM questionnaire a second time at the end of
the study.
TECHNOLOGY ACCEPTANCE MODEL
QUESTIONNAIRE DESIGN
Questionnaires were developed using Davis’s TAM18 to
evaluate the perceived ease of use and usefulness of HD1
and HD2. A modified TAM was adopted to ensure per-
ceived ease of use and usefulness of the devices were valid
and reliable predictors of user acceptance20–22 and appli-
cation convenience. The questionnaire consisted of six
parts and had 37 questions in total. The 37 questions were
distributed as follows: (1) five questions on demographics,
(2) 11 questions on perceived ease of use, (3) eight ques-
tions on perceived usefulness, (4) six questions on satisfac-
tion with the device, (5) four questions on willingness to
use, and (6) three questions on degree of willingness to
use the device. The first 29 questions were answered using
a 5-point Likert scale that ranged from 1 (strongly agree)
to 5 (strongly disagree); the degree of willingness to use
was measured on a 0-to-10 interval scale in which 0, 6, and
10 represented “no willingness at all,” “just acceptable”
(ie, the threshold for acceptance), and “total willingness,”
respectively.
DATA ANALYSIS
We used SPSS (version 21.0; IBM SPSS Statistics, IBM Taiwan
Corp, Taipei, Taiwan) to conduct data analysis. Analysis of the
participants also included a paired-sample t test and Pearson’s
χ2 test. Descriptive statistics were used to analyze the de-
mographic data. Finally, Cronbach’s α was calculated to
determine the reliability of the TAM. All statistical tests were
two-sided, and significance was established at a threshold
of P < .05.
October 2018
ETHICAL APPROVAL
This study was approved by the institutional review board
of the National Yang-Ming University Office of Research
and Development (IRB no. 980018) in 2009 for the study
period from 2009 to 2012. All data collected were coded
with encrypted personal identification.
RESULTS
Figure 1 shows the participants’ perceived usability, in terms
of ease of use, usefulness, satisfaction, and degree of willing-
ness to use, of HD1 and HD2. There were seven and 15 missing
data points from 2009 and 2012, respectively. Universally,
subjects perceived both devices as easy to use and useful.
They were satisfied with both tools and willing to recom-
mend them to others. As expected, HD2 with its superior
features showed significantly higher ratings than HD1 did
on almost all indicators.
Table 1 indicates the degree of participants’ willingness to
use and mutual comparisons. In 2009, when HD1 was intro-
duced, the subjects’ average scores to use the original paper
and HD1 were 5.64 and 6.68, with SDs of 2.17 and 1.81,
respectively. Subjects were significantly willing to use HD1
and preferred HD1 over paper. When HD2 was introduced
in 2012, the subjects’ average scores to use the original pa-
per, HD1, and HD2 tools were 5.76, 6.27, and 7.27, with
SDs of 2.56, 2.06, and 1.84, respectively. Subjects signifi-
cantly preferred HD2 among all the tools. The table does
not indicate that, in 2012, 52 of 71 subjects rated HD1 6
or higher, which indicated that they remained willing to
use it.
DISCUSSION
Properly designed mobile technology is attractive in long-
term care settings, because application of comprehensive
geriatric assessment is complex and time consuming and
staff in long-term care facilities are limited and usually lack
the necessary skills and support tools.14 Figure 1 shows the
high evaluation of both HD1 and HD2. Through scores
on almost all indicators, staff recognized the usability of both
mobile devices and were willing to use and recommend
them to others over traditional paper forms. Table 1 shows
that the degree of willingness to use HD1 in 2009 had an

a
FIGURE 1. Participants’ perceived usability in the two handheld devices. The asterisk (*) indicates significance at P < .05. Perceived
acceptance: 1, strongly agree; 2, somewhat agree; 3, neutral; 4, somewhat disagree; 5, strongly disagree.

Volume 36 | Number 10 CIN: Computers, Informatics, Nursing 503

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

FEATURE ARTICLE

average of 6.68, above the acceptance threshold, and was

HD2
—
—
—
statistically higher than the average of 5.64 for the paper
form, which was below the threshold. A similar pattern

<.001b
HD1
emerged in 2012 when comparing HD1, HD2, and paper.

—
—
P Value of Difference Comparison
We can observe the negative effect of new advanced tech-
nology on the old in the intention to use. Table 1 shows that
Paper System

staff perceived HD1 as less desirable than HD2. The staff’s

<.001b perceived degree of willingness to use HD2, which was
.06
—

7.27, was statistically higher than those of both paper and

HD1, which were 5.76 and 6.27, respectively. We were
not surprised because HD2’s improved features, such as font
Acceptance Thresholda

size, button size, weight, operating system, processor speed,

HD2

and screen navigation, made it superior to HD1 in almost

all usability indicators. New mobile technology with superior
<.001b
.429
.273

usability certainly affects the attractiveness of old technology.

This does not necessarily mean that HD1 became obso-
lete. The willingness to use HD1 decreased from 6.68 in
Table 1. Participants’ Perceived Usability of Various Tools When HD1 and HD2 Were Introduced

2009 to 6.27 in 2012, but both numbers were above the

acceptance threshold. Upon analyzing the willingness to use
5.76 (2.56)
6.27 (2.06)
7.27 (1.84)
Mean (SD)

HD1, the odds ratio was 2.74; 52 subjects (73%) remained

willing to use HD1 after HD2 became available.
Although we did not systematically examine the effects of
usability on product obsolescence, we believe the usability
of HD1 saved it from becoming obsolete. When designing
70
70
70
N

HD1 in 2009, we spent considerable time researching how

to make it excel at complex documentation. We developed its
HD1

NA
—
—

interface design principles at the beginning to ensure usabil-

ity.14 Our result showed that sound design could facilitate
P Value of Difference Comparison
Paper System

complex and time-consuming comprehensive assessments,

<.001b

and participants had strong willingness to use a device with

NA
—

a properly designed interface. As designer Dieter Rams said,

a proper design helps users understand a product and make
it useful.23 As shown in Figure 1, although HD2 in 2012
Acceptance Thresholda

scored overwhelmingly higher than HD1 in almost all us-

ability indicators, attitude toward usability of HD1 remained
positive. HD2 is preferable, but HD1 remains acceptable.
HD1

<.001b
.078

NA

The value of advanced features of new technology must

be evaluated together in terms of overall integrated usability.
The features of mobile hardware have evolved rapidly with
Significantly different between groups, P < .05.

user preference. For example, preferred screen size changed

from 4 to 4.3 inches in 2011 to 4.5 to 5 inches in 2014 and 5
5.64 (2.17)
6.68 (1.81)
Mean (SD)

to 5.5 inches in 2015; phones with screens 5 in and larger are

Abbreviation: NA, not available

the fastest growing category.24 Devices with 5.5- to 6-in

NA

screens can display relatively large fonts that allow for an eas-
ier reading experience,25,26 but the large display size raises
usability challenges such as how to carry and hold such a
113
113
NA
N

large device. We designed and introduced a handheld device

with a 6-in display in 2012 for our nurses and installed a
Paper system

hand or neck strap for easy carrying and holding. However,

HD1, with its small screen, possessed some favored usability
Six.
Tools

HD1
HD2

features. The smaller device was easier to carry, and the

b
a

stylus provided easier and more precise data entry.

504 CIN: Computers, Informatics, Nursing October 2018

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

 We found that participants were willing to use the 3.9-in
HD1 device, which was easy to operate and functioned
properly. Operation of a 4-in mobile screen generates the
fewest operational errors and possesses the appropriate
visual effects for a one-hand operation.27 Moreover, the
3.5- to 4-in screen is sufficiently small that most people can
reach every corner of the display, even with a single hand.28,29
According to The Mobile Web Intelligence Report Q3 2016 from
DeviceAtlas,30 5-in and larger phones are the fastest growing
categories, but 4-in devices—mostly Apple devices—still
comprise a large market share. Nearly 60% of users have
not yet upgraded to a larger screen; plenty remain who pre-
fer a smaller, but still powerful, 4-in device. The iPhone SE
is a smaller iPhone with a 6/6S-inspired look that ties the
SE to the flagship models, but the old design does mean
it is easier to grip and use with one hand.31,32 As we found,
old designs remain welcome even after a new design appears.
Strategies exist for confronting obsolescence. Proske et al33
suggested general strategies for long-living products that
avoid qualitative obsolescence that included designing for
reliability and robustness, repair and maintenance, upgrad-
ability, product attachment, and variability. Strategies for
mitigating obsolescence include planning to provide flexi-
bility, assuring the anticipated performance, monitoring
change, refurbishing early to accommodate change, and
designing for variability.34–36 These recommendations em-
phasize the value of hardware features.
We found that interface design of software features plays
a crucial role in the strategy of mobile technology. We veri-
fied the usability of both HD1 and HD2, and users remained
willing to use HD1 when HD2 overwhelmingly outperformed
HD1 in almost all hardware features.
We used the TAM to evaluate perceived ease of use and
usefulness of HD1 and HD2. Although we did not apply
the newer version of the TAM, items in our questionnaire
included the four variables of the unified theory of accep-
tance and use of technology (UTAUT) model. We conducted
a static-group comparison to identify the differences be-
tween the two devices. Venkatesh et al37 (2003) developed
the UTAUT model to explain employee technology accep-
tance and usability with four independent variables: perfor-
mance expectancy (usefulness in our TAM questionnaire),
effort expectancy (ease of use in our questionnaire), social
influence (willingness to use in our questionnaire), and facil-
itating conditions (employee training and system operation
guidance in our questionnaire). In 2012, the UTAUT238
added three more variables to define behavioral intention:
hedonic motivation, price value, and habit. Considering
the device was operated by healthcare staff engaged in di-
rect care, hedonic motivation and price value do not apply
to our study. Recent surveys consider the TAM one of the
most popular models to understand technology adoption,
Volume 36 | Number 10
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
and researchers have found that the TAM could explain
58.7% to 88% of the perceived usefulness and ease of use
and predict the adoption of technology.39,40
Currently, smartphone manufacturers launch new devices
every 2 to 3 months on average; the longest time between
new device launches is approximately 1 year, and mobile op-
erating systems are updated once every 6 to 12 months.41,42
According to consumers, the average smartphone and mo-
bile device life expectancy is currently 4.7 to 5.2 years, con-
tradicting the expected usage time of 2.5 to 2.7 years.33,43
Because general medical products are updated approxi-
mately every 7 to 10 years,44 obsolescence of mobile devices
in mobile health is a serious issue. Our study suggests that
this problem could be resolved if the usability of both hard-
ware and software is considered initially.
Healthcare systems that use mobile technology are not
merely a temporary phenomenon of technological develop-
ment, but they are a new care delivery model with effective
and innovative development.3,5,6 Mobile health has already
become an efficient way of “offering the right information
to the right person at the right time.”45,46 To avoid technol-
ogy obsolescence through proper usability design, this study
suggests the need for information and communication tech-
nology, and healthcare and nursing managers highly empha-
size the necessity of system usability design. This strategy of a
highly usable interface is especially crucial for small institu-
tions with relatively few resources (eg, nursing homes), sup-
portive healthcare staff (eg, nurse aids or volunteers), or
charitable long-term healthcare facilities (eg, child or elderly
welfare agencies).
CONCLUSION
A properly designed interface can help long-term care facilities
implement the complex and time-consuming comprehen-
sive geriatric assessment and minimize the wasteful replace-
ment of existing technology.
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