Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> The Early Remote Monitoring Architecture Adopted for Diabetes Patients (1990-2000) <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> The Early Remote Monitoring Architecture Adopted for Diabetes Patients (1990-2000) <s> Abstract The World-Wide Web (WWW) is increasingly being used as a platform to develop distributed applications, particularly in contexts, such as medical ones, where high usability and availability are required. In this paper we propose a methodology for the development of knowledge-based medical applications on the web, based on the use of an explicit domain ontology to automatically generate parts of the system. We describe a development environment, centred on the LISPWEB Common Lisp HTTP server, that supports this methodology, and we show how it facilitates the creation of complex web-based applications, by overcoming the limitations that normally affect the adequacy of the web for this purpose. Finally, we present an outline of a system for the management of diabetic patients built using the LISPWEB environment. <s> BIB002 </s> Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> The Early Remote Monitoring Architecture Adopted for Diabetes Patients (1990-2000) <s> In the context of the EU funded Telematic Management of Insulin-Dependent Diabetes Mellitus (T-IDDM) project, we have designed, developed and evaluated a telemedicine system for insulin dependent diabetic patients management. The system relies on the integration of two modules, a Patient Unit (PU) and a Medical Unit (MU), able to communicate over the Internet and the Public Switched Telephone Network. Using the PU, patients are allowed to automatically download their monitoring data from the blood glucose monitoring device, and to send them to the hospital data-base; moreover, they are supported in their every day self monitoring activity. The MU provides physicians with a set of tools for data visualization, data analysis and decision support, and allows them to send messages and/or therapeutic advice to the patients. The T-IDDM service has been evaluated through the application of a formal methodology, and has been used by European patients and physicians for about 18 months. The results obtained during the project demonstration, even if obtained on a pilot study of 12 subjects, show the feasibility of the T-IDDM telemedicine service, and seem to substantiate the hypothesis that the use of the system could present an advantage in the management of insulin dependent diabetic patients, by improving communications and, potentially, clinical outcomes. © 2002 Elsevier Science Ireland Ltd. All rights reserved. <s> BIB003 </s> Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> The Early Remote Monitoring Architecture Adopted for Diabetes Patients (1990-2000) <s> Abstract This paper presents the current features of the DIABTel telemedicine system and the evaluation outcomes of its use in clinical routine. This telemedicine system is designed to complement the daily care and intensive management of diabetic patients through telemonitoring and telecare services. The system comprises a patient unit (PU) used by patients in their day-to-day activities and a Medical Workstation used by physicians and nurses at hospitals. Both applications offer tools to collect, manage, view and interpret data and to exchange data and messages. The system was evaluated for usability, telemedical protocols, metabolic control and quality of life. This evaluation consisted in a 6-month cross-over pilot study with ten Type I diabetic patients. The results of the evaluation allowed assessment of the telemedicine protocols in terms of the number of communications/patient (21.6±7.7); days between communications (5.4±2.66); messages sent by physicians (118 text messages); and data and messages transmitted by patients (3524 blood glucose readings, 1649 day-to-day insulin adjustments, 24 exercise reports, ten diet modifications and 63 text messages). Physicians performed more therapeutic changes during the DIABTel period than in the control period. There was a trend towards HbA1c improvement during DIABTel use with no incidence in the number of hypoglycaemias. This pilot study demonstrates the feasibility of the DIABTel system in clinical routine use and its potential benefits for diabetes care: improving the availability of information necessary for therapy adjustments; offering new physician–patient communication tools; increasing patient empowerment and education; and showing a positive trend towards improving the metabolic control of patients. Further studies are needed to validate these findings and to promote telemedicine as an opportunity to better diabetes care. <s> BIB004 </s> Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> The Early Remote Monitoring Architecture Adopted for Diabetes Patients (1990-2000) <s> This review focuses on the burgeoning use of web-based systems allowing patient-initiated glucometer uploads to facilitate provider treatment intensification. Studies in type 1 diabetes tended to show equivalent HbA1c improvements in both intervention and control groups without statistically significant difference. In contrast, type 2 patients seemed to do better than controls with significant differences in HbA1c. Patients were the beneficiaries of web-based diabetes management both through savings in time and cost. Major obstacles to wider implementation are patient computer skills, adherence to the technology, architectural and technical design, and the need to reimburse providers for their care. <s> BIB005 </s> Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> The Early Remote Monitoring Architecture Adopted for Diabetes Patients (1990-2000) <s> Telemedicine is coming! President Obama has released a proposed fiscal year 2010 budget that indicates a commitment to advancing health care information technology as a way to cut health care costs and save lives.1 Interest in telemedicine from the business and insurance communities is climbing rapidly. Each week or month, a new telemedicine product for transmitting physiologic data and facilitating communication between patient and health care provider is announced. New trade organizations to promote the use of telemedicine have been formed, such as the CTIA and WWI. Each week brings an announcement of a new telemedicine system or collaboration between a technology company and a patient care organization to deliver telemedicine. New publications, Web sites, and meetings to discuss the implications of wireless communication, mobile health, telemedicine, and other terms for this phenomenon are springing up regularly. A small but rapidly expanding body of research has generally concluded that telemedicine for diabetes offers many benefits compared to in-person visits for selected types of clinical indications, such as for chronic follow-up, review of monitoring data, and assurance of adherence to practice guidelines.2 <s> BIB006 </s> Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> The Early Remote Monitoring Architecture Adopted for Diabetes Patients (1990-2000) <s> BACKGROUND ::: Information and communication technologies have long been acknowledged to support information sharing along the whole chain of care, from the clinic to the homes of patients and their relatives. Thus they are increasingly being considered for improving the delivery of health care services also in light of clinical and technological achievements that propose new treatments requiring a tighter interaction among patients and physicians. ::: ::: ::: METHODS ::: The multiagent paradigm has been utilized within an architecture for delivering telemedicine services to chronic outpatients at their domiciles and enforcing cooperation among patients, caregivers, and different members of the health care staff. The architecture sees each communication device such as a palmtop, smart phone, or personal digital assistant as a separate agent upon which different services are deployed, including telemetry, reminders, notifications, and alarms. Decoupling services from agents account for a highly configurable environment applicable to almost any context that can be customized as needed. ::: ::: ::: RESULTS ::: The architecture has been used for designing and implementing a prototypical software infrastructure, called LifePhone, that runs on several communication devices. A basic set of services has been devised with which we were able to configure two different applications that address long-term and short-term monitoring scenarios for diabetes patients. The long-term scenario encompasses telemetry and reminder services for patients undergoing peritoneal dialysis, which is a treatment for chronic renal failure, a diabetes complication. The short-term scenario incorporates telemetry and remote alarms and is applicable for training patients to use an artificial pancreas. ::: ::: ::: CONCLUSIONS ::: Our experiments proved that an infrastructure such as LifePhone can be used successfully for bridging the interaction gap that exists among all the components of a health care delivery process, improving the quality of service and possibly reducing the overall costs of health care. Furthermore, the modularity of services allows for more complex scenarios encompassing data analysis or even involving actors at multiple institutions in order to better support the overall health care organization. <s> BIB007
The first prototypical systems attempting a systematic collection of data from diabetes patients started to appear in the late 1990s BIB005 . The limitations of the technology and the brittleness of the network connections available at that time accounted for an architecture encompassing two separate elements, a Patient Unit (PU) and a Medical Unit (MU) that provided different services to those two user classes BIB007 . The PU was located at the patient's home and was implemented as an application usually running on a Personal Computer (PC). Its main purpose was data acquisition, which was mostly accomplished manually by the patient himself, even though sometimes it also occurred automatically by interfacing the PU with sensing devices BIB003 . The MU acted as a concentrator for patient data and was located instead at the clinic in order to be always accessible by the treating staff for consultation. The PU and MU exchanged data asynchronously through network connections established by modems over regular telephone lines, as shown in Figure 1 . Sometimes the PU, or part of it, was also implemented on a Personal Digital Assistant (PDA). These were small portable devices with limited computational and no networking capabilities that had to be placed on a docking station wired to a PC for accomplishing any network operation. As such, they privileged mobility and availability with respect to connectivity. Nevertheless, since the whole connectivity model was inherently asynchronous and real-time monitoring was not affordable at that time, at least in the beginning, the tradeoff seemed to be reasonable. The strict separation between the PU and MU was dictated by the discontinued nature of the connection and the need to render each component independent from the other one. This separation also allowed additional services to be easily integrated into each component since both stored patient data locally. As a matter of fact, it soon became clear that, for remote monitoring systems to be effective, besides just offering plain data collection, they had to show a proactive behavior processing those data at the knowledge level BIB001 BIB002 BIB006 . Thus, on the patient side, additional services were introduced addressing self-management such as reminders, calculators for selecting each time the proper amount of insulin to be administered, comprehensive charts providing a better overview of the disease or even educational tools BIB004 . On the doctor's side, services for promptly recognizing and managing abnormal patient conditions were devised instead.