A generic telemedicine infrastructure for monitoring an artificial pancreas trial

Health information technology foresight for Iran: A Delphi study of experts' views to inform future policymaking

BACKGROUND

Policymakers require a systematic approach when planning for information technology needs in healthcare.

OBJECTIVE

The aim of this study was to obtain experts' predictions of future health information technology (HIT) needs until 2025 for Iran in relation to the relative importance of key technologies, expected timeframe of realisation, areas that may be impacted upon and obstacles to achieving these goals.

METHOD

This article presents results from the third phase (a Delphi study) of a larger mixed-method study. Policymakers from the Iranian Ministry of Health and faculty members from different medical universities across the country who were expert in the field of HIT were invited to participate (n = 61).

RESULTS

Participants (39) completed the first-round questionnaire and 24 completed the second. The development of personal health records (n = 32, 82.0%), the development of clinical decision-making systems (n = 30, 76.9%) and the use of business intelligence for collecting and analysing clinical and financial data (n = 32, 82.0%) were predicted to occur after 2025. The healthcare areas predicted to experience the greatest impact from most HITs were facilitating patient-provider communication and improving healthcare quality. Key barriers to achieving HITs were related to weaknesses in planning and limited financial resources for most technologies.

CONCLUSION

By identifying the areas of impact and the barriers to achieving the HIT goals, more accurate planning is possible and resources can be allocated according to priorities.

Formulating Telemedicine Strategies in Isfahan University of Medical Sciences

INTRODUCTION

The use of telemedicine technology can lead to an equitable distribution of specialized care. There are numerous influencing factors which should be identified for successful implementation and efficacy of telemedicine. The aim of this study was to evaluate current situation and internal and external environment of Isfahan University of Medical Sciences (IUMS) and prepare telemedicine development strategies for IUMS.

METHODS

This study was an applied cross-sectional mixed method study which was conducted between July 2014 to November 2016 and in five phases in IUMS. a) Evaluating Internal and external factors (IFE & EFE); b) Formulating goals; c) Identifying and prioritizing strategic problems; d) Setting objectives; and e) formulating the strategies to develop telemedicine in IUMS. The research sample included 147 of IUMS inner customers and stakeholders in the first phase (census) and 14 in the second phase (Purposive sampling based on more work experience). In the first phase, to analyze obtained data of two researcher-made questionnaires, measures of central tendency and dispersion (frequency, percent and mean) were calculated using SPSS. To evaluate internal and external factors and formulating strategies was used TOWS matrix. And finally, to select optimal strategies for telemedicine developing quantitative strategic planning matrix was used.

RESULTS

The final score of internal and external factors evaluation was 2.67 and 2.68, respectively. According to the strategic position and action evaluation (SPACE), telemedicine strategic planning in IUMS was in aggressive posture. Because the numbers were closer to 2.5 can be concluded that based on internal factors the organization was in moderate to strong and based on external factors was in a moderate level and neither have a serious positive feature for use the opportunities outside the organization and suffered a serious threat from the outside of organization. Finally, we formulated 14 strategies to develop telemedicine in IUMS as followings: 5 SO, 2 ST, 5 WO, and 2 WT strategies.

CONCLUSION

Telemedicine development in IUMS is located in poor aggressive posture. Therefore, IUMS can develop telemedicine and subsequently, in this study, strategies were developed to preserve and retain healthcare workers, practical studies, data confidentiality and security programs, and other issues.

Trusting telemedicine: A discussion on risks, safety, legal implications and liability of involved stakeholders

OBJECTIVES

The main purpose of the article is to raise awareness among all the involved stakeholders about the risks and legal implications connected to the development and use of modern telemedicine systems. Particular focus is given to the class of "active" telemedicine systems, that imply a real-world, non-mediated, interaction with the final user. A secondary objective is to give an overview of the European legal framework that applies to these systems, in the effort to avoid defensive medicine practices and fears, which might be a barrier to their broader adoption.

METHODS

We leverage on the experience gained during two international telemedicine projects, namely MobiGuide (pilot studies conducted in Spain and Italy) and AP@home (clinical trials enrolled patients in Italy, France, the Netherlands, United Kingdom, Austria and Germany), whose development our group has significantly contributed to in the last 4 years, to create a map of the potential criticalities of active telemedicine systems and comment upon the legal framework that applies to them. Two workshops have been organized in December 2015 and March 2016 where the topic has been discussed in round tables with system developers, researchers, physicians, nurses, legal experts, healthcare economists and administrators.

RESULTS

We identified 8 features that generate relevant risks from our example use cases. These features generalize to a broad set of telemedicine applications, and suggest insights on possible risk mitigation strategies. We also discuss the relevant European legal framework that regulate this class of systems, providing pointers to specific norms and highlighting possible liability profiles for involved stakeholders.

CONCLUSIONS

Patients are more and more willing to adopt telemedicine systems to improve home care and day-by-day self-management. An essential step towards a broader adoption of these systems consists in increasing their compliance with existing regulations and better defining responsibilities for all the involved stakeholders.

An Environment for Guidelinebased Decision Support Systems for Outpatients Monitoring

Objectives: We propose an architecture for monitoring outpatients that relies on mobile technologies for acquiring data. The goal is to better control the onset of possible side effects between the scheduled visits at the clinic.

Methods: We analyze the architectural components required to ensure a high level of abstraction from data. Clinical practice guidelines were formalized with Alium, an authoring tool based on the PROforma language, using SNOMED-CT as a terminology standard. The Alium engine is accessible through a set of APIs that may be leveraged for implementing an application based on standard web technologies to be used by doctors at the clinic. Data sent by patients using mobile devices need to be complemented with those already available in the Electronic Health Record to generate personalized recommendations. Thus a middleware pursuing data abstraction is required. To comply with current standards, we adopted the HL7 Virtual Medical Record for Clinical Decision Support Logical Model, Release 2.

Results: The developed architecture for monitoring outpatients includes: (1) a guideline-based Decision Support System accessible through a web application that helps the doctors with prevention, diagnosis and treatment of therapy side effects; (2) an application for mobile devices, which allows patients to regularly send data to the clinic. In order to tailor the monitoring procedures to the specific patient, the Decision Support System also helps physicians with the configuration of the mobile application, suggesting the data to be collected and the associated collection frequency that may change over time, according to the individual patient’s conditions. A proof of concept has been developed with a system for monitoring the side effects of chemo-radiotherapy in head and neck cancer patients.

Conclusions: Our environment introduces two main innovation elements with respect to similar works available in the literature. First, in order to meet the specific patients’ needs, in our work the Decision Support System also helps the physicians in properly configuring the mobile application. Then the Decision Support System is also continuously fed by patient-reported outcomes.

Parental evaluation of a telemonitoring service for children with Type 1 Diabetes

Introduction In the past years, we developed a telemonitoring service for young patients affected by Type 1 Diabetes. The service provides data to the clinical staff and offers an important tool to the parents, that are able to oversee in real time their children. The aim of this work was to analyze the parents' perceived usefulness of the service. Methods The service was tested by the parents of 31 children enrolled in a seven-day clinical trial during a summer camp. To study the parents' perception we proposed and analyzed two questionnaires. A baseline questionnaire focused on the daily management and implications of their children's diabetes, while a post-study one measured the perceived benefits of telemonitoring. Questionnaires also included free text comment spaces. Results Analysis of the baseline questionnaires underlined the parents' suffering and fatigue: 51% of total responses showed a negative tendency and the mean value of the perceived quality of life was 64.13 in a 0-100 scale. In the post-study questionnaires about half of the parents believed in a possible improvement adopting telemonitoring. Moreover, the foreseen improvement in quality of life was significant, increasing from 64.13 to 78.39 ( p-value = 0.0001). The analysis of free text comments highlighted an improvement in mood, and parents' commitment was also proved by their willingness to pay for the service (median = 200 euro/year). Discussion A high number of parents appreciated the telemonitoring service and were confident that it could improve communication with physicians as well as the family's own peace of mind.

Remote Blood Glucose Monitoring in mHealth Scenarios: A Review

Glucose concentration in the blood stream is a critical vital parameter and an effective monitoring of this quantity is crucial for diabetes treatment and intensive care management. Effective bio-sensing technology and advanced signal processing are therefore of unquestioned importance for blood glucose monitoring. Nevertheless, collecting measurements only represents part of the process as another critical task involves delivering the collected measures to the treating specialists and caregivers. These include the clinical staff, the patient's significant other, his/her family members, and many other actors helping with the patient treatment that may be located far away from him/her. In all of these cases, a remote monitoring system, in charge of delivering the relevant information to the right player, becomes an important part of the sensing architecture. In this paper, we review how the remote monitoring architectures have evolved over time, paralleling the progress in the Information and Communication Technologies, and describe our experiences with the design of telemedicine systems for blood glucose monitoring in three medical applications. The paper ends summarizing the lessons learned through the experiences of the authors and discussing the challenges arising from a large-scale integration of sensors and actuators.

Health-Enabling and Ambient Assistive Technologies: Past, Present, Future

BACKGROUND

During the last decades, health-enabling and ambient assistive technologies became of considerable relevance for new informatics-based forms of diagnosis, prevention, and therapy.

OBJECTIVES

To describe the state of the art of health-enabling and ambient assistive technologies in 1992 and today, and its evolution over the last 25 years as well as to project where the field is expected to be in the next 25 years. In the context of this review, we define health-enabling and ambient assistive technologies as ambiently used sensor-based information and communication technologies, aiming at contributing to a person's health and health care as well as to her or his quality of life.

METHODS

Systematic review of all original articles with research focus in all volumes of the IMIA Yearbook of Medical Informatics. Surveying authors independently on key projects and visions as well as on their lessons learned in the context of health-enabling and ambient assistive technologies and summarizing their answers. Surveying authors independently on their expectations for the future and summarizing their answers.

RESULTS

IMIA Yearbook papers containing statements on health-enabling and ambient assistive technologies appear first in 2002. These papers form a minor part of published research articles in medical informatics. However, during recent years the number of articles published has increased significantly. Key projects were identified. There was a clear progress on the use of technologies. However proof of diagnostic relevance and therapeutic efficacy remains still limited. Reforming health care processes and focussing more on patient needs are required.

CONCLUSIONS

Health-enabling and ambient assistive technologies remain an important field for future health care and for interdisciplinary research. More and more publications assume that a person's home and their interaction therein, are becoming important components in health care provision, assessment, and management.

A Digital Ecosystem of Diabetes Data and Technology: Services, Systems, and Tools Enabled by Wearables, Sensors, and Apps

The management of type 1 diabetes (T1D) ideally involves regimented measurement of various health signals; constant interpretation of diverse kinds of data; and consistent cohesion between patients, caregivers, and health care professionals (HCPs). In the context of myriad factors that influence blood glucose dynamics for each individual patient (eg, medication, activity, diet, stress, sleep quality, hormones, environment), such coordination of self-management and clinical care is a great challenge, amplified by the routine unavailability of many types of data thought to be useful in diabetes decision-making. While much remains to be understood about the physiology of diabetes and blood glucose dynamics at the level of the individual, recent and emerging medical and consumer technologies are helping the diabetes community to take great strides toward truly personalized, real-time, data-driven management of this chronic disease. This review describes "connected" technologies--such as smartphone apps, and wearable devices and sensors--which comprise part of a new digital ecosystem of data-driven tools that can link patients and their care teams for precision management of diabetes. These connected technologies are rich sources of physiologic, behavioral, and contextual data that can be integrated and analyzed in "the cloud" for research into personal models of glycemic dynamics, and employed in a multitude of applications for mobile health (mHealth) and telemedicine in diabetes care.

Designing an artificial pancreas architecture: the AP@home experience

The latest achievements in sensor technologies for blood glucose level monitoring, pump miniaturization for insulin delivery, and the availability of portable computing devices are paving the way toward the artificial pancreas as a treatment for diabetes patients. This device encompasses a controller unit that oversees the administration of insulin micro-boluses and continuously drives the pump based on blood glucose readings acquired in real time. In order to foster the research on the artificial pancreas and prepare for its adoption as a therapy, the European Union in 2010 funded the AP@home project, following a series of efforts already ongoing in the USA. This paper, authored by members of the AP@home consortium, reports on the technical issues concerning the design and implementation of an architecture supporting the exploitation of an artificial pancreas platform. First a PC-based platform was developed by the authors to prove the effectiveness and reliability of the algorithms responsible for insulin administration. A mobile-based one was then adopted to improve the comfort for the patients. Both platforms were tested on real patients, and a description of the goals, the achievements, and the major shortcomings that emerged during those trials is also reported in the paper.

Gquest: modeling patient questionnaires and administering them through a mobile platform application

BACKGROUND

The use of surveys is becoming popular in the health care industry for acquiring information useful to the accomplishment of several studies. Besides their exploitation on a large scale for conducting epidemiological studies, surveys are being increasingly carried out on a narrower perspective through the administration of questionnaires aimed at assessing the quality of life perceived by patients or their clinical status during mid- or long-term treatments. This is useful for managing resources or optimizing and individualizing treatments.

OBJECTIVES

This paper describes Gquest, a platform for modeling, generating and administering questionnaires through mobile devices such as smartphones or tablets. Gquest was motivated by the need of administering questionnaires during home treatments, albeit its applicability is rather general. The main requirement was to have a very simple, clean and easy to use platform able to support (a) physicians in the design and delivery of questionnaires and (b) outpatients in sending self-recorded outcomes to the clinical staff.

METHODS

Gquest has two basic components. The first one is a model devised for representing questionnaires which is extremely flexible. It allows the generation of questions and answers of different types, supports adaptivity in the dialog with the user and enforces simple consistency rules for checking his input. The second component is an application able to run instances of those questionnaires. It downloads questionnaires over the air in terms of XML files from a server and stores them locally into the mobile repository. Questionnaires become then available to the user, who in our case is a patient or one of his relatives. The user can select which one to fill-in, according to his needs and/or the specific treatment protocol. The selected questionnaire may be filled-in all at once or be completed in subsequent steps over time since any input provided is persisted on a local database. Finally, when a questionnaire is closed all the answers are transparently synchronized to a server for further evaluation or statistical purposes.

RESULTS

The platform has been exploited and tested in two medical domains where questionnaires have very different purposes; a quality of life pilot survey involving patients with atrial fibrillation within the EU-funded project MobiGuide, and an investigation of the users' needs during the requirements elicitation phase of a telemedicine project for the safe discharge of fragile patients.

CONCLUSIONS

Gquest proved to be a suitable tool for dealing with a wide variety of question types and has been positively accepted by the patients enrolled in the pilot study.

Trends on integrating framework of applications or data. Findings from the section on health and clinical management

OBJECTIVE

To summarize current excellent research and trends in the field of Health and Clinical management.

METHODS

Synopsis of the articles selected for the IMIA Yearbook 21014 RESULTS: A comprehensive review of papers published in 2013 was performed by querying PubMed. 1079 were reviewed as papers without authors, without abstract or smaller than 4 pages were excluded from the selection. The editors reviewed all papers and 15 papers selected and provided to to international reviewers. Four papers from international peer-reviewed journals were finally selected for the Health and Clinical Management section.

CONCLUSION

Many telemedicine applications are tested nowadays in medical situation, but the challenges emphasized by the best papers selection focus on the ability of proposing integrative frameworks for applications or data in order to handle efficiency of health and clinical management.

Monitoring Artificial Pancreas Trials Through Agent-based Technologies: A Case Report

The increase in the availability and reliability of network connections lets envision systems supporting a continuous remote monitoring of clinical parameters useful either for overseeing chronic diseases or for following clinical trials involving outpatients. We report here the results achieved by a telemedicine infrastructure that has been linked to an artificial pancreas platform and used during a trial of the AP@home project, funded by the European Union. The telemedicine infrastructure is based on a multiagent paradigm and is able to deliver to the clinic any information concerning the patient status and the operation of the artificial pancreas. A web application has also been developed, so that the clinic staff and the researchers involved in the design of the blood glucose control algorithms are able to follow the ongoing experiments. Albeit the duration of the experiments in the trial discussed in the article was limited to only 2 days, the system proved to be successful for monitoring patients, in particular overnight when the patients are sleeping. Based on that outcome we can conclude that the infrastructure is suitable for the purpose of accomplishing an intelligent monitoring of an artificial pancreas either during longer trials or whenever that system will be used as a routine treatment.

Assessment of Patient Perceptions About Web Telemonitoring Applied to Artificial Pancreas Use at Home

Patients with chronic diseases as well as health care systems could benefit from telemedicine applications such as remote monitoring (RM). RM relies on a device that sends patients' health data to a remote server accessible by care teams. Recent smartphone-based artificial pancreas (AP) systems collect comprehensive set of information and could therefore support the development of RM applied to diabetes. To better understand how RM could be integrated in future AP systems, we wanted to get patients' opinion on this concept, as they are the final users of these systems. An online questionnaire with 11 items was sent to 20 experienced patients who tested AP and RM during our recent outpatient studies in France and Italy. We received 17 answers. All patients considered that during their participation in trials, RM was useful, reassuring, and essential. One-third wouldn't have participated without it. When AP is commercialized, 88% of respondents think that AP should go with a RM tool, but it should be activated only at certain times, at first use or in case of difficulties (82%). Participants ask for technical support when a device fails (88%) and for medical help in case of prolonged hyperglycemia (65%) or severe or repeated hypoglycemia (53%), but not after each case of hypoglycemia (6%). More than 75% think that RM could help them to improve their blood glucose control. This preliminary work indicates that patients expect RM to be part of future AP development. Larger studies remain to be performed to investigate its usefulness and potential economic effectiveness.

First use of model predictive control in outpatient wearable artificial pancreas

OBJECTIVE

Inpatient studies suggest that model predictive control (MPC) is one of the most promising algorithms for artificial pancreas (AP). So far, outpatient trials have used hypo/hyperglycemia-mitigation or medical-expert systems. In this study, we report the first wearable AP outpatient study based on MPC and investigate specifically its ability to control postprandial glucose, one of the major challenges in glucose control.

RESEARCH DESIGN AND METHODS

A new modular MPC algorithm has been designed focusing on meal control. Six type 1 diabetes mellitus patients underwent 42-h experiments: sensor-augmented pump therapy in the first 14 h (open-loop) and closed-loop in the remaining 28 h.

RESULTS

MPC showed satisfactory dinner control versus open-loop: time-in-target (70-180 mg/dL) 94.83 vs. 68.2% and time-in-hypo 1.25 vs. 11.9%. Overnight control was also satisfactory: time-in-target 89.4 vs. 85.0% and time-in-hypo: 0.00 vs. 8.19%.

CONCLUSIONS

This outpatient study confirms inpatient evidence of suitability of MPC-based strategies for AP. These encouraging results pave the way to randomized crossover outpatient studies.

DiAs web monitoring: a real-time remote monitoring system designed for artificial pancreas outpatient trials

BACKGROUND

Developments in an artificial pancreas (AP) for patients with type 1 diabetes have allowed a move toward performing outpatient clinical trials. "Home-like" environment implies specific protocol and system adaptations among which the introduction of remote monitoring is meaningful. We present a novel tool allowing multiple patients to monitor AP use in home-like settings.

METHODS

We investigated existing systems, performed interviews of experienced clinical teams, listed required features, and drew several mockups of the user interface. The resulting application was tested on the bench before it was used in three outpatient studies representing 3480 h of remote monitoring.

RESULTS

Our tool, called DiAs Web Monitoring (DWM), is a web-based application that ensures reception, storage, and display of data sent by AP systems. Continuous glucose monitoring (CGM) and insulin delivery data are presented in a colored chart to facilitate reading and interpretation. Several subjects can be monitored simultaneously on the same screen, and alerts are triggered to help detect events such as hypoglycemia or CGM failures. In the third trial, DWM received approximately 460 data per subject per hour: 77% for log messages, 5% for CGM data. More than 97% of transmissions were achieved in less than 5 min.

CONCLUSIONS

Transition from a hospital setting to home-like conditions requires specific AP supervision to which remote monitoring systems can contribute valuably. DiAs Web Monitoring worked properly when tested in our outpatient studies. It could facilitate subject monitoring and even accelerate medical and technical assessment of the AP. It should now be adapted for long-term studies with an enhanced notification feature.