The benefits of thrombolytic treatment are time-dependent,1 and early patient arrival at a hospital that provides thrombolytic treatment is critical. Early recognition of stroke symptoms, rapid screening, accurate information on nearby hospitals that provide acute stroke care, and rapid dispatch can reduce the delay in thrombolytic treatment, which may improve patient outcomes. There have been several efforts to reduce time interval from stroke onset to initiation of the thrombolytic treatment. Recently, information technologies, such as computerized physician order entry system and mobile, real-time audio-video streaming telemedicine devices,2-4 have been successfully implemented in this process that aims at reducing in-hospital or pre-hospital time delay.

Smartphones are becoming widely used for medical purposes.5,6 The benefits of smartphones include portability, easy accessibility, and location sensing frameworks that use a Global Positioning System (GPS). We therefore developed and introduce 'Stroke 119', a smartphone application that aids rapid stroke screening and may reduce hospital arrival time for stroke patients.

We developed a smartphone application named "Stroke 119", which refers to the emergency telephone number in Korea (equivalent to 9-1-1 in the United States). Stroke 119 was developed for multi-platforms, including iPhone™ (https://itunes.apple.com/kr/app/noejoljung119/id509755048?mt=8) and Android™ smartphones (https://play.google.com/store/apps/details?id=com.jnheo.stroke119), using the iPhone software development toolkit (SDK 3.0, Apple Inc., Cupertino, CA, USA)7 and the Android SDK (SDK r20.0.3).8 Map data for the application were adopted from the open map (Daum map API v3, Daum Comp., Seoul, Korea).9 For hospital registration, a web page (http://stroke119.org) was developed using PHP and MySQL.

The Stroke 119 application was developed as a hybrid app, meaning that the map portion of the app was made as a web application, thus ensuring that all hospital map data are up-to-date and identical across the platforms. Distances between hospitals and the user are calculated on the server-side, making the application faster and more reliable. A distance calculation algorithm was adopted from the Haversine formula.10

The Stroke 119 application may be useful for effective thrombolytic treatment in several ways. Simple screening tools have been developed for rapid and easy diagnosis of stroke. Although these screening tools are reliable,11,13 their widespread use is limited because the user needs to have the screening protocol on hand. Previously, these tools were tested on emergency delivery service personnel. With our application, the screening tool is on hand as long as the user has a smartphone; the Stroke 119 application therefore can be used in the general population.

Although smartphones are increasingly used for medical purposes, almost all applications were ones that provide medical information on hand using their portability. However, their usefulness can be expanded by using built-in functions of the smartphones such as the GPS and gyrometer. Use of the GPS is a notable feature of the Stroke 119 application, which enables the application to determine a user's location and search for nearby hospitals. This allows stroke victims, witnesses, and emergency delivery service personnel to find nearby hospitals that provide thrombolytic treatment in real time. Stroke patients, who lack information on an appropriate stroke care hospitals, may visit hospitals far from their location or hospitals that are not ready to provide the thrombolytic treatment, which may delay the thrombolytic treatment, as it was demonstrated in previous studies in that referral from other hospital was associated with delayed arrival to an appropriate acute care hospital.14,15 Therefore, the Stroke 119 application may facilitate finding hospitals that provide thrombolysis, thus shortening hospital arrival times.

While this application might be useful for the general population, the primary target of this application would be stroke patients or their families, who are admitted to the hospital or visited outpatient clinic, as well as paramedics of the emergency delivery services. Stroke patients and/or their families can easily download it while they were being admitted and when stroke nurses or physicians provide stroke education at discharge for them, or the patient visits to the outpatient clinic.

The usefulness of this application may depend on the accuracy of information provided by the registered hospitals. We primarily invited neurology training hospitals and hospitals that provide acute stroke care for registration because they are accessible within one or two hours in most areas of Korea, and play major roles in acute stroke care.16,17 In countries with a certification system for primary stroke centers or stroke units, those certified hospitals also could be included in registration. Early arrival at a hospital and identification of the nearby hospitals that provide an appropriate care are critical in other medical conditions such as acute myocardial infarction and trauma as well as acute stroke. The concept, which uses a rapid screening tool and the GPS for helping stoke victims find nearby hospitals, can be applicable also in those emergent conditions.

This study has limitations. This application has been developed based on hypothesis that the use of application may reduce the time intervals from stroke onset to hospital arrival of a stroke victim, and the frequency of referrals from other hospitals that do not provide thrombolytic treatment. Although this hypothesis was based on solid evidence that the Cincinnati Prehospital Stroke Scale is valid, and that referral from another hospital is a significant factor of delayed presentation, we could not provide data on the effectiveness of this application. Therefore, it is inconclusive that this application can improve patient outcome in real practice.

In conclusion, we developed a smartphone application that provides rapid self-screening for stroke, identifies nearby hospitals that provide thrombolytic treatment, and facilitates calling emergency services. This application may reduce hospital arrival times and delays of thrombolytic treatment.