Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> The Switch to a Service Oriented Architecture (2000-2010) <s> OBJECTIVES ::: This paper presents a multi-access service for the management of diabetes mellitus patients and the results of its assessment in two Italian clinical sites. ::: ::: ::: METHODS ::: The service was evaluated for one year in order to prove the advantages of these kind of systems from different points of view. In this paper the clinical, usability and technical outcomes are presented. ::: ::: ::: RESULTS ::: The evaluation results show that, thanks to the high flexibility of the implemented service, the telemedicine management of diabetes patients is feasible, well accepted by patients and clinically effective. However, in Italy the problem of quantifying the reimbursement rate of telematic services and the impact they have on the organization are factors that may hamper their introduction in routine clinical practice. ::: ::: ::: CONCLUSIONS ::: The evaluation study showed that the telemedicine intervention has been satisfactory both for physicians because it allows to constantly monitor the patients' blood glucose level and for patients because it strengthens their motivation to self-monitor the metabolic situation. <s> BIB001 </s> Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> The Switch to a Service Oriented Architecture (2000-2010) <s> Background:Diabetes mellitus is one of the chronic diseases exploiting the largest number of telemedicine systems. Our research group has been involved since 1996 in two projects funded by the European Union proposing innovative architectures and services according to the best current medical practices and advances in the information technology area.Method:We propose an enhanced architecture for telemedicine giving rise to a multitier application. The lower tier is represented by a mobile phone hosting the patient unit able to acquire data and provide first-level advice to the patient. The patient unit also facilitates interaction with the health care center, representing the higher tier, by automatically uploading data and receiving back any therapeutic plan supplied by the physician. On the patient's side the mobile phone exploits Bluetooth technology and therefore acts as a hub for a wireless network, possibly including several devices in addition to the glucometer.Results:A new system architecture bas... <s> BIB002 </s> Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> The Switch to a Service Oriented Architecture (2000-2010) <s> The growing availability of continuous data from medical devices in diabetes management makes it crucial to define novel information technology architectures for efficient data storage, data transmission, and data visualization. The new paradigm of care demands the sharing of information in interoperable systems as the only way to support patient care in a continuum of care scenario. The technological platforms should support all the services required by the actors involved in the care process, located in different scenarios and managing diverse information for different purposes. This article presents basic criteria for defining flexible and adaptive architectures that are capable of interoperating with external systems, and integrating medical devices and decision support tools to extract all the relevant knowledge to support diabetes care. <s> BIB003 </s> Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> The Switch to a Service Oriented Architecture (2000-2010) <s> Abstract Purpose Advanced information technologies joined to the increasing use of continuous medical devices for monitoring and treatment, have made possible the definition of a new telemedical diabetes care scenario based on a hand-held Personal Assistant (PA). This paper describes the architecture, functionality and implementation of the PA, which communicates different medical devices in a personal wireless network. Description of the system The PA is a mobile system for patients with diabetes connected to a telemedical center. The software design follows a modular approach to make the integration of medical devices or new functionalities independent from the rest of its components. Physicians can remotely control medical devices from the telemedicine server through the integration of the Common Object Request Broker Architecture (CORBA) and mobile GPRS communications. Data about PA modules’ usage and patients’ behavior evaluation come from a pervasive tracing system implemented into the PA. Results and discussion The PA architecture has been technically validated with commercially available medical devices during a clinical experiment for ambulatory monitoring and expert feedback through telemedicine. The clinical experiment has allowed defining patients’ patterns of usage and preferred scenarios and it has proved the Personal Assistant's feasibility. The patients showed high acceptability and interest in the system as recorded in the usability and utility questionnaires. Future work will be devoted to the validation of the system with automatic control strategies from the telemedical center as well as with closed-loop control algorithms. <s> BIB004 </s> Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> The Switch to a Service Oriented Architecture (2000-2010) <s> AIMS ::: Flexible intensive insulin therapy (FIT) has become the reference standard in type 1 diabetes. Besides carbohydrate counting (CHO), it requires the use of algorithms to adjust prandial insulin doses to the number of CHO portions. As recourse to standard algorithms is usual when initiating FIT, the use of personalized algorithms would also allow more precise adjustments to be made. The aim of the present study was to validate personalized prandial algorithms for FIT as proposed by Howorka et al. in 1990. ::: ::: ::: METHODS ::: We conducted a 4-month observational study of 35 patients with type 1 diabetes, treated with FIT for at least 6 months, who were already using Howorka's prandial algorithms (meal-related and correctional insulin doses for blood glucose increases induced by CHO). These patients were asked to use a personal digital assistant (PDA) phone with an electronic diary (instead of a paper one) to take advantage of the computerized data-collection system to assess the quality of postprandial metabolic control. ::: ::: ::: RESULTS ::: Whatever the number of CHO portions, mean postprandial blood glucose values remained close to the target of 7.8mmol/L, and the compensatory algorithm allowed precise correction of preprandial hyperglycaemia. In fact, the algorithms for meal-related and correctional insulin doses at the end of the study did not differ significantly from those initially calculated, but they generally differed from one patient to another. ::: ::: ::: CONCLUSION ::: In type 1 diabetic patients treated with FIT, the use of individualized parameters permits fast and accurate adjustment of mealtime insulin doses, leading to good control of the postprandial state. <s> BIB005 </s> Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> The Switch to a Service Oriented Architecture (2000-2010) <s> This paper illustrates an agent-based architecture for a telemedicine platform providing monitoring services to chronic patients and enabling remote home care. The architecture encompasses remote agents located by the patients and a central agent located at the treating site. Remote agents are mostly implemented on mobile devices in order to maximize their portability and be able to follow patients during their daily activities. Those agents exploit wireless connectivity both on the short range through the Bluetooth protocol for interacting with data acquisition devices, and on the long range through GPRS/UMTS for exchanging data with the treating site. The central agent besides keeping the clinical staff up to date with the patient state, may also autonomously send out notifications, alarms and reminders to remote agents. <s> BIB006 </s> Remote Blood Glucose Monitoring in mHealth Scenarios: A Review <s> The Switch to a Service Oriented Architecture (2000-2010) <s> This paper illustrates a platform based on a general architecture for implementing home care services for chronic patients composed of a Remote Care Unit located at a patient's home and a Health Care Center Unit located at the treating center. The Remote Care Unit may be deployed on multiple platforms including PCs, mobile phones and even embedded devices not equipped with monitor, and may be configured to support many interoperability issues occurring among the parties involved in a health care delivery process. The platform may be tailored to match the specific issues of any chronic disease supporting either data acquisition as well as customized reminders and notifications from the center. Remote Care Unit platforms are also able to exploit multiple channels for acquiring data, including wireless links with medical devices, speech interaction and graphical user interaction. In this paper a couple of applications addressing the needs of diabetic and nephropatic patients developed on top of that platform are also introduced. <s> BIB007
The strong distinction between PU and MU faded during the first decade of the new century, as telemedicine services began to be deployed over stable network connections, eventually accessed through mobile devices such as smartphones BIB002 that were just appearing on the market. The previous partitioning into two opposite halves, each one targeting a specific set of functionalities did not provide the required flexibility anymore. Instead, the switch to a basic client-server paradigm, such as the one used by plain web applications, granted ubiquitous access to a set of centralized services, resulting in a Service Oriented Architecture (SOA) BIB003 . The SOA also allowed the rapid deployment of new services, avoiding the need to undergo complex installations or configurations at every patient's location. Moreover, leveraging the interoperability among the components, it also favored a multi-modal access exploiting different technologies that were emerging at that time, such as Short Message Service (SMS), Wireless Application Protocol (WAP), automatic speech recognition or TV set-top boxes, as shown in Figure 2 . The switch to the SOA paralleled the PDAs gradual demise. In fact, since PDAs were mainly connectionless devices, they could not stand the widespread availability of network connections. However, despite smartphones were hailed as the successors of the PDAs, during the first decade of the current century, they had very poor computational power and limited display capabilities that made an immediate replacement of PDAs almost impossible. Thus, it was not unusual to observe some blending of SOA with older architectures depending on the devices used BIB004 . The early versions of the Diabeo system BIB005 , for example, still used a PDA to implement a logbook where the patient kept track of all his BGL readings. The PDA also offered a decision support system automatically proposing prandial and basal insulin dosages. However, every other functionality was made available through a web application that could be accessed anywhere using PCs or other appliances able to run a web browser. The M 2 DM project BIB001 represented instead a step forward since it was based on a pure SOA architecture, and the interfacing of glucometers was accomplished using the Roche Acculink system. Despite the latter was a closed system using a proprietary modem technology, it simplified the remote transfer of patient data fully preserving the SOA paradigm in that project. Incidentally, we may note that glucose sensors lag far behind current ICT standards usually found in other appliances, and, in most cases, they are not compliant with those standards at all. As a matter of fact, across the first decade of the century, glucometers even lacked basic Universal Serial Bus (USB) or wireless capabilities and their interfacing occurred just through serial connections or dedicated infrared transceivers hooked up to the PC serial port. Eventually, by the end of the first decade, some projects began to use smartphones for encapsulating specific services on the patient's side, such as alerts and reminders BIB006 , therefore complementing the SOA as it happened in the LifePhone project BIB007 .