Development of a Smartphone Application to Enable Remote Monitoring in the Outpatient Management of Cirrhotic Ascites


  • Phil Ha Monash Health
  • Sherryne Warner Monash Health
  • Paul O’Neil Monash Health
  • Patricia Anderson Monash Health
  • William Sievert Monash Health
Keywords: Health, remote monitoring, cirrhosis, ascites


Patients who develop hepatic decompensation with ascites have a poor prognosis and often experience other complications including spontaneous bacterial peritonitis, hepatic encephalopathy and variceal bleeding. We hypothesised that smartphone (SP)-enabled remote monitoring of patients with ascites may enable early detection of infection and acute decompensation, facilitate timely intervention and improve patient outcomes. Aim:  We aimed to design, develop and implement a remote monitoring system (RMS) for outpatients with cirrhotic ascites. Method: We undertook surveys with patients and hepatologists to quantify the demand for a RMS and identify issues regarding implementation. A smartphone and a web-based application were developed as a RMS. Patients used the RMS in a 6-week prospective non-randomised trial.  Results: We surveyed 27 patients (mean age 56 years, 18 (67%) were male, 16 (59%) had Childs Pugh B cirrhosis, and 20 (74%) had a history of alcoholic liver disease) and 5 hepatologists. There were 19 patients (70%) who reported that they would use a RMS. The RMS was used by 10 patients for a mean 53.8days (11-70), who entered 20.6 (0-71) updates. A total of 18 automated alerts occurred. 22% of automated alerts resulted in clinically significant changes to management, such as inpatient admission n=1 (6%), early outpatient appointment n=1 (6%) and reinforced adherence n=2 (11%). Conclusion:   We have successfully designed an internet-enabled RMS for outpatients with cirrhotic ascites that could be used as an adjunct to existing outpatient services. Future studies will optimise the alert thresholds, assess long-term patient adoption and quantify clinical impact.


European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol. 2010 Sep;53(3):397–417.

Runyon BA, AASLD Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis: an update. Hepatol Baltim Md. 2009 Jun;49(6):2087–107.

Le S, Spelman T, Chong C-P, Ha P, Sahhar L, Lim J, et al. Could Adherence to Quality of Care Indicators for Hospitalized Patients With Cirrhosis-Related Ascites Improve Clinical Outcomes? Am J Gastroenterol. 2016 Jan;111(1):87–92.

D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: A systematic review of 118 studies - Journal of Hepatology. J Hepatol. 2006 Jan;44(1):217–31.

Morando F, Maresio G, Piano S, Fasolato S, Cavallin M, Romano A, et al. How to improve care in outpatients with cirrhosis and ascites: A new model of care coordination by consultant hepatologists. J Hepatol. 2013 Aug;59(2):257–64.

Google. Google Forms. 1600 Amphitheatre Parkway, Mountain View, CA 94043, United States: Google Inc.

Foundation E. Eclipse IDE [Internet]. Eclipse Foundaton; 2014. Available from:

Twilio, Inc. Twilio [Internet]. Communication APIs for SMS, Voice, Video and Authentication. 2014. Available from:

Parse, Inc. Menlo Park, CA, USA: Parse, inc; 2014.

Microsoft. Microsoft Excel. Redmond, Washington, USA: Microsoft Corporation;

Wiesner R, Edwards E, Freeman R, Harper A, Kim R, Kamath P, et al. Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology. 2003 Jan;124(1):91–6.

Biggins SW, Kim WR, Terrault NA, Saab S, Balan V, Schiano T, et al. Evidence-based incorporation of serum sodium concentration into MELD. Gastroenterology. 2006 May;130(6):1652–60.

Singh S. Smartphone Market Share by Country - Q3 2013: Android Dominates Outside US, Windows Phone Grows in Europe | Tech-Thoughts by Sameer Singh [Internet]. Available at: accessed 19 March 2014

Lunden I. 6.1B Smartphone Users Globally By 2020, Overtaking Basic Fixed Phone Subscriptions. TechCrunch. Available at: accessed on 9 January 2018.

Charani E, Castro-Sánchez E, Moore LSP, Holmes A. Do smartphone applications in healthcare require a governance and legal framework? It depends on the application! BMC Med. 2014;12:29.

Savitz E. 5 Ways Mobile Apps Will Transform Healthcare. Forbes. Available at: accessed 7 January 2018

Cui M, Wu X, Mao J, Wang X, Nie M. T2DM Self-Management via Smartphone Applications: A Systematic Review and Meta-Analysis. PloS One. 2016;11(11):e0166718.

Haze KA, Lynaugh J. Building patient relationships: a smartphone application supporting communication between teenagers with asthma and the RN care coordinator. Comput Inform Nurs CIN. 2013 Jun;31(6):266-271; quiz 272-273.

Licskai C, Sands TW, Ferrone M. Development and pilot testing of a mobile health solution for asthma self-management: asthma action plan smartphone application pilot study. Can Respir J. 2013 Aug;20(4):301–6.

Johnston NW, Lambert K, Hussack P, de Verdier MG, Higenbottam T, Lewis J, et al. Detection of COPD Exacerbations and compliance with patient-reported daily symptom diaries using a smart phone-based information system [corrected]. Chest. 2013 Aug;144(2):507–14.

Işik AH, Güler I. Pulse oximeter based mobile biotelemetry application. Stud Health Technol Inform. 2012;181:197–201.

Kirwan M, Vandelanotte C, Fenning A, Duncan MJ. Diabetes self-management smartphone application for adults with type 1 diabetes: randomized controlled trial. J Med Internet Res. 2013 Nov 13;15(11):e235.

Hewson DJ, Jaber R, Chkeir A, Hammoud A, Gupta D, Bassement J, et al. Development of a monitoring system for physical frailty in independent elderly. Conf Proc Annu Int Conf IEEE Eng Med Biol Soc IEEE Eng Med Biol Soc Annu Conf. 2013;2013:6215–8.

Nishiguchi S, Ito H, Yamada M, Yoshitomi H, Furu M, Ito T, et al. Self-assessment tool of disease activity of rheumatoid arthritis by using a smartphone application. Telemed J E-Health Off J Am Telemed Assoc. 2014 Mar;20(3):235–40.

Shinohara A, Ito T, Ura T, Nishiguchi S, Ito H, Yamada M, et al. Development of lifelog sharing system for rheumatoid arthritis patients using smartphone. Conf Proc Annu Int Conf IEEE Eng Med Biol Soc IEEE Eng Med Biol Soc Annu Conf. 2013;2013:7266–9.

Wagner R, Ganz A. PAGAS: Portable and Accurate Gait Analysis System. Conf Proc Annu Int Conf IEEE Eng Med Biol Soc IEEE Eng Med Biol Soc Annu Conf. 2012;2012:280–3.

Yamada M, Aoyama T, Mori S, Nishiguchi S, Okamoto K, Ito T, et al. Objective assessment of abnormal gait in patients with rheumatoid arthritis using a smartphone. Rheumatol Int. 2012 Dec;32(12):3869–74.

Faurholt-Jepsen M, Vinberg M, Christensen EM, Frost M, Bardram J, Kessing LV. Daily electronic self-monitoring of subjective and objective symptoms in bipolar disorder—the MONARCA trial protocol (MONitoring, treAtment and pRediCtion of bipolAr disorder episodes): a randomised controlled single-blind trial. BMJ Open. 2013;3(7):e003353. doi:10.1136/bmjopen-2013-003353.

Lu K, Marino NE, Russell D, Singareddy A, Zhang D, Hardi A, et al. Use of Short Message Service and Smartphone Applications in the Management of Surgical Patients: A Systematic Review. Telemed J E-Health Off J Am Telemed Assoc. 2017 Nov 7;

Soto-Perez-De-Celis E, Kim H, Rojo-Castillo MP, Sun C-L, Chavarri-Guerra Y, Navarrete-Reyes AP, et al. A pilot study of an accelerometer-equipped smartphone to monitor older adults with cancer receiving chemotherapy in Mexico. J Geriatr Oncol. 2017 Oct 7;

Cai RA, Beste D, Chaplin H, Varakliotis S, Suffield L, Josephs F, et al. Developing and Evaluating JIApp: Acceptability and Usability of a Smartphone App System to Improve Self-Management in Young People With Juvenile Idiopathic Arthritis. JMIR MHealth UHealth. 2017 Aug 15;5(8):e121.

Verma M, Navarro V. Patient-centered care: A new paradigm for chronic liver disease. Hepatol Baltim Md. 2015 Oct;62(4):988–90.

Mellinger JL, Volk ML. Multidisciplinary Management of Patients With Cirrhosis: A Need for Care Coordination. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2013 Mar;11(3):217–23.

Bajaj JS, Heuman DM, Sterling RK, Sanyal AJ, Siddiqui M, Matherly S, et al. Validation of EncephalApp, Smartphone-Based Stroop Test, for the Diagnosis of Covert Hepatic Encephalopathy. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2015 Oct;13(10):1828–1835.e1.

Bajaj JS, Thacker LR, Heuman DM, Fuchs M, Sterling RK, Sanyal AJ, et al. The Stroop Smartphone App is A Short and Valid Method to Screen for Minimal Hepatic Encephalopathy. Hepatol Baltim Md. 2013 Sep;58(3):1122–32.

Chaudhry SI, Mattera JA, Curtis JP, Spertus JA, Herrin J, Lin Z, et al. Telemonitoring in patients with heart failure. N Engl J Med. 2010 Dec 9;363(24):2301–9.

Cleland JGF, Louis AA, Rigby AS, Janssens U, Balk AHMM, TEN-HMS Investigators. Noninvasive home telemonitoring for patients with heart failure at high risk of recurrent admission and death: the Trans-European Network-Home-Care Management System (TEN-HMS) study. J Am Coll Cardiol. 2005 May 17;45(10):1654–64.

Giordano A, Scalvini S, Zanelli E, Corrà U, Longobardi GL, Ricci VA, et al. Multicenter randomised trial on home-based telemanagement to prevent hospital readmission of patients with chronic heart failure. Int J Cardiol. 2009 Jan 9;131(2):192–9.

Koehler F, Winkler S, Schieber M, Sechtem U, Stangl K, Böhm M, et al. Telemedicine in heart failure: pre-specified and exploratory subgroup analyses from the TIM-HF trial. Int J Cardiol. 2012 Nov 29;161(3):143–50.

Lyngå P, Persson H, Hägg-Martinell A, Hägglund E, Hagerman I, Langius-Eklöf A, et al. Weight monitoring in patients with severe heart failure (WISH). A randomized controlled trial. Eur J Heart Fail. 2012 Apr;14(4):438–44.

Ledwidge MT, O’Hanlon R, Lalor L, Travers B, Edwards N, Kelly D, et al. Can individualized weight monitoring using the HeartPhone algorithm improve sensitivity for clinical deterioration of heart failure? Eur J Heart Fail. 2013 Apr;15(4):447–55.

Zhang J, Goode KM, Cuddihy PE, Cleland JGF, TEN-HMS Investigators. Predicting hospitalization due to worsening heart failure using daily weight measurement: analysis of the Trans-European Network-Home-Care Management System (TEN-HMS) study. Eur J Heart Fail. 2009 Apr;11(4):420–7.

Seto E, Leonard KJ, Cafazzo JA, Barnsley J, Masino C, Ross HJ. Mobile phone-based telemonitoring for heart failure management: a randomized controlled trial. J Med Internet Res. 2012 Feb 16;14(1):e31.

Commonwealth of Australia: Australian Bureau of StatistiCommonwealth of Australia: Australian Bureau of Statistics. Personal internet use. Australian Bureau of Statistics. 2014. Available at: accessed 8 October 2015

Commonwealth of Australia: Australian Bureau of Statistics. Personal Internet Use [Internet]. Australian Bureau of Statistics. 2014. Available from: accessed 8 October 2015

Drumm J, White N, Swiegers M, Davie M. Mobile Consumer Survey 2017 : The Australian Cut. Deloitte Touche Tohmatsu Limited; 2017.

How to Cite
Ha, P., Warner, S., O’Neil, P., Anderson, P., & Sievert, W. (2018). Development of a Smartphone Application to Enable Remote Monitoring in the Outpatient Management of Cirrhotic Ascites. Journal of the International Society for Telemedicine and EHealth, 6(1), e7 (1-9).
Original Research