Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> Discussion <s> An ontology-based multi-agent architecture for distributed health-care information systems. - <s> BIB001 </s> Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> Discussion <s> Healthcare applications are considered as promising fields for wireless sensor networks, where patients can be monitored using wireless medical sensor networks (WMSNs). Current WMSN healthcare research trends focus on patient reliable communication, patient mobility, and energy-efficient routing, as a few examples. However, deploying new technologies in healthcare applications without considering security makes patient privacy vulnerable. Moreover, the physiological data of an individual are highly sensitive. Therefore, security is a paramount requirement of healthcare applications, especially in the case of patient privacy, if the patient has an embarrassing disease. This paper discusses the security and privacy issues in healthcare application using WMSNs. We highlight some popular healthcare projects using wireless medical sensor networks, and discuss their security. Our aim is to instigate discussion on these critical issues since the success of healthcare application depends directly on patient security and privacy, for ethic as well as legal reasons. In addition, we discuss the issues with existing security mechanisms, and sketch out the important security requirements for such applications. In addition, the paper reviews existing schemes that have been recently proposed to provide security solutions in wireless healthcare scenarios. Finally, the paper ends up with a summary of open security research issues that need to be explored for future healthcare applications using WMSNs. <s> BIB002 </s> Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> Discussion <s> Insulin therapy has enabled patients with diabetes to maintain blood glucose control to lead healthier lives. Today, rather than injecting insulin manually using syringes, a patient can use a device such as an insulin pump to deliver insulin programmatically. This allows for more granular insulin delivery while attaining blood glucose control. Insulin pump system features have increasingly benefited patients, but the complexity of the resulting system has grown in parallel. As a result, security breaches that can negatively affect patient health are now possible. ::: ::: Rather than focus on the security of a single device, we concentrate on protecting the security of the entire system. In this article, we describe the security issues as they pertain to an insulin pump system that includes an embedded system of components, which include the insulin pump, continuous glucose management system, blood glucose monitor, and other associated devices (e.g., a mobile phone or personal computer). We detail not only the growing wireless communication threat in each system component, but also describe additional threats to the system (e.g., availability and integrity). Our goal is to help create a trustworthy infusion pump system that will ultimately strengthen pump safety, and we describe mitigating solutions to address identified security issues. <s> BIB003 </s> Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> Discussion <s> Abstract Telemedicine is increasingly becoming a reality in medical care for the elderly. We performed a systematic literature review on telemedicine healthcare concepts for older patients. We included controlled studies in an ambulant setting that analyzed telemedicine interventions involving patients aged ≥60 years. 1585 articles matched the specified search criteria, thereof, 68 could be included in the review. Applications address an array of mostly frequent diseases, e.g. cardiovascular disease ( N = 37) or diabetes ( N = 18). The majority of patients is still living at home and is able to handle the telemedicine devices by themselves. In 59 of 68 articles (87%), the intervention can be categorized as monitoring. The largest proportion of telemedicine interventions consisted of measurements of vital signs combined with personal interaction between healthcare provider and patient ( N = 24), and concepts with only personal interaction (telephone or videoconferencing, N = 14). The studies show predominantly positive results with a clear trend towards better results for “behavioral” endpoints, e.g. adherence to medication or diet, and self-efficacy compared to results for medical outcomes (e.g. blood pressure, or mortality), quality of life, and economic outcomes (e.g. costs or hospitalization). However, in 26 of 68 included studies, patients with characteristic limitations for older patients (e.g. cognitive and visual impairment, communication barriers, hearing problems) were excluded. A considerable number of projects use rather sophisticated technology (e.g. videoconferencing), limiting ready translation into routine care. Future research should focus on how to adapt systems to the individual needs and resources of elderly patients within the specific frameworks of the respective national healthcare systems. <s> BIB004 </s> Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> Discussion <s> Advances supported by emerging wearable technologies in healthcare promise patients a provision of high quality of care. Wearable computing systems represent one of the most thrust areas used to transform traditional healthcare systems into active systems able to continuously monitor and control the patients' health in order to manage their care at an early stage. However, their proliferation creates challenges related to data management and integration. The diversity and variety of wearable data related to healthcare, their huge volume and their distribution make data processing and analytics more difficult. In this paper, we propose a generic semantic big data architecture based on the "Knowledge as a Service" approach to cope with heterogeneity and scalability challenges. Our main contribution focuses on enriching the NIST Big Data model with semantics in order to smartly understand the collected data, and generate more accurate and valuable information by correlating scattered medical data stemming from multiple wearable devices or/and from other distributed data sources. We have implemented and evaluated a Wearable KaaS platform to smartly manage heterogeneous data coming from wearable devices in order to assist the physicians in supervising the patient health evolution and keep the patient up-to-date about his/her status. <s> BIB005 </s> Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> Discussion <s> INTRODUCTION ::: The rapid development of sensors and communication technologies enable the growth of new innovative services in healthcare, such as Telemedicine. An essential ingredient in the development of a telemedicine system and its final acceptance by end users are usability studies. The principles of usability engineering, evaluations and telemedicine are well established, and it may contribute to the adoption and eventually deployment of such systems and services. An in-depth usability analysis, including performance and attitude measures, requires knowledge about available usability techniques, and is depending on the amount of resources. Therefore it is worth investigating how usability methods are applied in developing telemedicine systems. Our hypothesis is: with increasing research and development of telemedicine systems, we expect that various usability methods are more equally employed for different end-user groups and applications. ::: ::: ::: METHOD ::: A literature survey was conducted to find telemedicine systems that have been evaluated for usability or ease of use. The elements of the PICO framework were used as a basis for the selection criteria in the literature search. The search was not limited by year. Two independent reviewers screened all search results first by title, and then by abstract for inclusion. Articles were included up to May 2015. ::: ::: ::: RESULTS ::: In total, 127 publications were included in this survey. The number of publications on telemedicine systems significantly increased after 2008. Older adults and end-users with cardiovascular conditions were among largest target end-user groups. Remote monitoring systems were found the most, in 90 publications. Questionnaires are the most common means for evaluating telemedicine systems, and were found in 88 publications. Questionnaires are used frequently in studies focusing on cardiovascular diseases, Parkinson's disease and older adult conditions. Interviews are found the most in publications related to stroke. In total 71% of the publications were trial-orientated and the remaining process orientated. An increase in telemedicine research, development and applications is found worldwide, with the majority of publications conducted in America. ::: ::: ::: DISCUSSION AND CONCLUSION ::: Monitoring patients in their homes can lead to better healthcare at lower costs which implies an increased demand of new healthcare strategies like telemedicine. We expected that with the increase in telemedicine research and development, a greater range of usability methods would also be employed in the included publications. This is not the case. Researchers employed questionnaires as a preferred usability method for each type of telemedicine system and most end-users. However, in process-orientated studies a greater range of usability evaluations were applied, with fewer differences found in the amount of publications for each evaluation method. Questionnaires enable researchers to evaluate a system quickly on end users, as it requires less expertise on the evaluation method compared to the other methods. They are easily distributed and are customizable. The use of questionnaires is therefore an evaluation method of choice for a variety of telemedicine systems and end-users. <s> BIB006 </s> Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> Discussion <s> An efficient PSOSAA algorithm for the medical monitoring and managing application of the hospital information system is proposed.Introduce the information cloud system based on IoT for hospitals.The cloud computing and IoT technologies are used in medical area.Presents a model architecture for remote monitoring cloud platform of healthcare information. Cloud computing and the Internet of Things are the two hot points in the Internet application field. The application of the two new technologies is in hot discussion and research, but quite less on the field of medical monitoring and managing application. Thus, in this paper, we study and analyze the application of cloud computing and the Internet of Things on the medical field. And we manage to make a combination of the two techniques in the medical monitoring and managing field. The model architecture for remote monitoring cloud platform of healthcare information (RMCPHI) was established firstly. Then the RMCPHI architecture was analyzed. Finally an efficient PSOSAA algorithm was proposed for the medical monitoring and managing application of cloud computing. Simulation results showed that our proposed scheme can improve the efficiency about 50%. <s> BIB007 </s> Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> Discussion <s> Background Telemedicine has seen substantial growth in the past 20 years, related to technologic advancements and evolving reimbursement policies. The risks and opportunities of neurosurgical telemedicine are nuanced. Methods We reviewed general and peer-reviewed literature as it relates to telemedicine and neurosurgery, with particular attention to best practices, relevant state and federal policy conditions, economic evaluations, and prospective clinical studies. Results Despite technologic development, growing interest, and increasing reimbursement opportunities, telemedicine's utilization remains limited because of concerns regarding an apparent lack of need for telemedicine services, lack of widespread reimbursement, lack of interstate licensure reciprocity, lack of universal access to necessary technology, concerns about maintaining patient confidentiality, and concerns and limited precedent regarding liability issues. The Veterans Health Administration, a component of the U.S. Department of Veterans Affairs, represents a setting in which these concerns can be largely obviated and is a model for telemedicine best practices. Results from the VA demonstrate substantial cost savings and patient satisfaction with remote care for chronic neurologic conditions. Overall, the economic and clinical benefits of telemedicine will likely come from 1) diminished travel times and lost work time for patients; 2) remote consultation of subspecialty experts, such as neurosurgeons; and 3) remote consultation to assist with triage and care in time-sensitive scenarios, including acute stroke care and “teletrauma.” Conclusions Telemedicine is effective in many health care scenarios and will become more relevant to neurosurgical patient care. We favor proceeding with legislation to reduce barriers to telemedicine's growth. <s> BIB008
In this paper, we reviewed the evolution of the architectures adopted for the remote monitoring of glucose and diabetes data over the past few decades. We also illustrated our experiences in developing some telemedicine systems that were used for overseeing the operation of AP devices in adults or adolescents and for centralizing the management of blood glucose infusion rates in preterm newborns treated at the NICU. Based on those experiences, we observed that the integration of portable medical devices into remote monitoring architectures poses several issues. The first one is related with the design and development of new medical devices. We know that this process is inherently very long, mainly due to the several regulatory steps required to ensure its safe use on patients. Since, on the contrary, the evolution of ICT technologies occurs at a much faster rate, a possible solution for being successful with this integration is to take into account some sort of backward compatibility. This should be accomplished with the twofold purpose of interfacing with devices still based on old technologies and standards but quickly moving to more recent ones as soon as the devices are updated. We followed this approach exactly in our projects concerning the remote monitoring of AP devices, frequently updating the architecture over a limited time period to support its interfacing with devices using each time updated technology standards, as described in Sections 4.1 and 4.2. A second issue is that, differently from the ICT market, a plug-and-play approach for medical devices faces several further challenges, especially for what concerns the safety of the final system and the liability in case of errors. While, in the past, the connection among medical devices mainly occurred through wires and just required a basic serial protocol, the adoption of wireless connectivity opened up new security issues that had to be properly addressed. Security and encryption protocols are already available and regularly used in a transparent way in modern ICT applications. However, they require extensive memory and computational capabilities that are still unsuitable for resource limited devices such as CGM sensors and insulin pumps BIB002 . Mitigating solutions have been proposed BIB003 , and the Diabetes Technology Society (DTS) has recently introduced a cyber-security standard (DTSec) to be adopted for securely interconnecting medical devices  . In the meantime, however, manufacturers have adopted solutions based on proprietary ciphers, and it will take some time before an effective standardization will actually take place. Interfacing with these devices, therefore, currently requires a close cooperation with manufacturers. Another issue is related to the importance of taking care of the final users of a system. Once the prototype has been completed and safety issues have been addressed and verified, developers should deeply consider suggestions coming from the actual users in order to make their system more targeted to its final context of use BIB006 . This becomes even more important when different actors are involved, including fragile or older patients BIB004 . Thus, in this review, we also addressed the issue of patient's perception. In particular, analyzing the questionnaires administered to adults during the trials held at hotels and at home, we observed that patients were concerned about being effectively safeguarded by the telemedicine service. To this aim, possible improvements might include the integration of an automatic alerting system that not only notifies the physicians about the onset of dangerous situations for the patients, but also keeps the patients themselves in the loop so that they may feel more tightly monitored and safe. Such an involvement has been experimented in the adolescents trial exploiting the AP described in Section 5, where parents highly appreciated to be included in the loop, as this enabled them to oversee the status of their children in real time. As for the methodological standpoint, the large amount of data generated by the automatic feed of a multitude of sensors, such as those envisioned by the Internet of Things BIB007 , is expected to exceed the investigative capabilities of a single clinical team. Addressing this issue poses several challenges, ranging from the development of new communication architectures supporting the massive usage of cloud computing  , to the integration of heterogenous data coming from different sources BIB005 so that interpretation may be accomplished mostly automatically using ontology and terminology servers implemented as distributed agents BIB001 . Finally, on the regulatory side, many questions are still open concerning the storage and the exchange of sensitive data such as those originated by medical devices. Every country has its own regulations, and, quite often, system architectures should be adapted to comply with these. The most common hurdles are given by the ownership of medical data, the agreements to be settled with the institutions managing the servers where those data are being stored or processed, and the possibility to exchange them over public networks BIB008 .