Gunnar Hartvigsen

Features of Mobile Diabetes Applications: Review of the Literature and Analysis of Current Applications Compared Against Evidence-Based Guidelines

Background Interest in mobile health (mHealth) applications for self-management of diabetes is growing. In July 2009, we found 60 diabetes applications on iTunes for iPhone; by February 2011 the number had increased by more than 400% to 260. Other mobile platforms reflect a similar trend. Despite the growth, research on both the design and the use of diabetes mHealth applications is scarce. Furthermore, the potential influence of social media on diabetes mHealth applications is largely unexplored. Objective Our objective was to study the salient features of mobile applications for diabetes care, in contrast to clinical guideline recommendations for diabetes self-management. These clinical guidelines are published by health authorities or associations such as the National Institute for Health and Clinical Excellence in the United Kingdom and the American Diabetes Association. Methods We searched online vendor markets (online stores for Apple iPhone, Google Android, BlackBerry, and Nokia Symbian), journal databases, and gray literature related to diabetes mobile applications. We included applications that featured a component for self-monitoring of blood glucose and excluded applications without English-language user interfaces, as well as those intended exclusively for health care professionals. We surveyed the following features: (1) self-monitoring: (1.1) blood glucose, (1.2) weight, (1.3) physical activity, (1.4) diet, (1.5) insulin and medication, and (1.6) blood pressure, (2) education, (3) disease-related alerts and reminders, (4) integration of social media functions, (5) disease-related data export and communication, and (6) synchronization with personal health record (PHR) systems or patient portals. We then contrasted the prevalence of these features with guideline recommendations. Results The search resulted in 973 matches, of which 137 met the selection criteria. The four most prevalent features of the applications available on the online markets (n = 101) were (1) insulin and medication recording, 63 (62%), (2) data export and communication, 61 (60%), (3) diet recording, 47 (47%), and (4) weight management, 43 (43%). From the literature search (n = 26), the most prevalent features were (1) PHR or Web server synchronization, 18 (69%), (2) insulin and medication recording, 17 (65%), (3) diet recording, 17 (65%), and (4) data export and communication, 16 (62%). Interestingly, although clinical guidelines widely refer to the importance of education, this is missing from the top functionalities in both cases. Conclusions While a wide selection of mobile applications seems to be available for people with diabetes, this study shows there are obvious gaps between the evidence-based recommendations and the functionality used in study interventions or found in online markets. Current results confirm personalized education as an underrepresented feature in diabetes mobile applications. We found no studies evaluating social media concepts in diabetes self-management on mobile devices, and its potential remains largely unexplored.

Current status and future perspectives in telecare for elderly people suffering from chronic diseases

Summary We reviewed the literature on home telecare for elderly patients suffering from chronic diseases. Articles published between 1990 and 2007 were identified via the PubMed database. The literature search yielded 485 papers. After reviewing the title and abstract from each, 54 were selected for closer examination. They were published in 37 different journals. The number of papers increased from one in 1997 to 14 in 2006. The diseases in which home telecare had been used were diabetes (14 studies), heart failure (13 studies), cognitive impairment (dementia and/or Alzheimers disease, 10 studies), chronic obstructive pulmonary disease (5 studies), chronic wounds (4 studies) and mobility disabilities (4 studies). Patients were generally satisfied with home telecare, but they preferred a combination of home telecare with conventional health-care delivery. Health-care professionals were positive about telecare. Users felt that on many occasions telecare led to a reduction in costs due to time savings and avoidance of travelling. Even though there were important benefits from home telecare, there are organizational, ethical, legal, design, usability and other matters that need to be resolved before widespread implementation can occur.

Mobile Phone-Based Self-Management Tools for Type 2 Diabetes: The Few Touch Application

Background: Mobile phones and other mobile information and communication technology applications and technologies hold great potential as a basis for powerful patient-operated self-management tools within diabetes. The work presented shows how such tools can be designed for supporting lifestyle changes among people with type 2 diabetes and how these were perceived by a group of 12 patients during a 6-month period. Method: The study used focus groups, interviews, feasibility testing, questionnaires, paper prototyping, and prototyping of both software and hardware components. The design process was iterative, addressing the various elements several times at an increasing level of detail. The final test of the application was done qualitatively in everyday settings in a cohort of 12 people with type 2 diabetes, aged 44–70 (four men and eight women). Results: A mobile phone-based system called the Few Touch application was developed. The system includes an off-the-shelf blood glucose (BG) meter, a tailor-made step counter, and software for recording food habits and providing feedback on how users perform in relation to their own personal goals. User feedback from the 6-month user intervention demonstrated good usability of the tested system, and several of the participants adjusted their medication, food habits, and/or physical activity. Of the five different functionalities, the cohort considered the BG sensor system the best. Conclusions: It was shown that it is possible and feasible to design an application where several sensors and feedback applications are integrated in an overall system. The presented Few Touch application challenges people with type 2 diabetes to think about how they can improve their health, providing them with a way to capture and analyze relevant personal information about their disease. The half-year user intervention demonstrated that the system had a motivational effect on the users.

Mobile Health Applications to Assist Patients with Diabetes: Lessons Learned and Design Implications

Self-management is critical to achieving diabetes treatment goals. Mobile phones and Bluetooth® can support self-management and lifestyle changes for chronic diseases such as diabetes. A mobile health (mHealth) research platform—the Few Touch Application (FTA)—is a tool designed to support the self-management of diabetes. The FTA consists of a mobile phone-based diabetes diary, which can be updated both manually from user input and automatically by wireless data transfer, and which provides personalized decision support for the achievement of personal health goals. Studies and applications (apps) based on FTAs have included: (1) automatic transfer of blood glucose (BG) data; (2) short message service (SMS)-based education for type 1 diabetes (T1DM); (3) a diabetes diary for type 2 diabetes (T2DM); (4) integrating a patient diabetes diary with health care (HC) providers; (5) a diabetes diary for T1DM; (6) a food picture diary for T1DM; (7) physical activity monitoring for T2DM; (8) nutrition information for T2DM; (9) context sensitivity in mobile self-help tools; and (10) modeling of BG using mobile phones. We have analyzed the performance of these 10 FTA-based apps to identify lessons for designing the most effective mHealth apps. From each of the 10 apps of FTA, respectively, we conclude: (1) automatic BG data transfer is easy to use and provides reassurance; (2) SMS-based education facilitates parent-child communication in T1DM; (3) the T2DM mobile phone diary encourages reflection; (4) the mobile phone diary enhances discussion between patients and HC professionals; (5) the T1DM mobile phone diary is useful and motivational; (6) the T1DM mobile phone picture diary is useful in identifying treatment obstacles; (7) the step counter with automatic data transfer promotes motivation and increases physical activity in T2DM; (8) food information on a phone for T2DM should not be at a detailed level; (9) context sensitivity has good prospects and is possible to implement on todays phones; and (10) BG modeling on mobile phones is promising for motivated T1DM users. We expect that the following elements will be important in future FTA designs: (A) automatic data transfer when possible; (B) motivational and visual user interfaces; (C) apps with considerable health benefits in relation to the effort required; (D) dynamic usage, e.g., both personal and together with HC personnel, long-/short-term perspective; and (E) inclusion of context sensitivity in apps. We conclude that mHealth apps will empower patients to take a more active role in managing their own health.

Home telecare technologies for the elderly.

There are many home telecare technologies which have been developed specifically for chronic diseases and there are some more generic technologies that could be used as well. For home telecare, the equipment must be certified, the operational routines must be reformed, the infrastructure must be in place, the market must be prepared, the health authorities must be convinced that the system will work and the cost-effectiveness must be evaluated. Organizational and societal changes, such as cost reduction policies and an aging population, are the main driving forces for the development of home telecare, especially for elderly patients. At the moment there is no holistic model for scientific evaluation from different perspectives (e.g. clinical, legal, technical). We suggest that more research on home telecare and its effects needs to be conducted, in order to provide evidence for optimizing the use of this promising technique.

Knowledge-based systems for strategic market planning in small firms

Abstract This paper gives an overview of strategic planning and decision-making in small firms, together with a discussion of the use of knowledge-based systems in strategic market planning. Furthermore, we describe the STRATEX system, which is a knowledge-based system for strategic market-planning in the export trade of fish and fisheries products. The results of the pilot system development of STRATEX are briefly presented, along with a discussion of needs for further developments in this field.

Performance of the First Combined Smartwatch and Smartphone Diabetes Diary Application Study

Background: Wearable computing has long been described as the solution to many health challenges. However, the use of this technology as a diabetes patient self-management tool has not been fully explored. A promising platform for this use is the smartwatch—a wrist-worn device that not only tells time but also provides internet connection and ability to communicate information to and from a mobile phone. Method: Over 9 months, the design of a diabetes diary application for a smartwatch was completed using agile development methods. The system, including a two-way communication between the applications on the smartwatch and mobile phone, was tested with 6 people with type 1 diabetes. A small number of participants was deliberately chosen due to ensure an efficient use of resources on a novel system. Results: The designed smartwatch system displays the time, day, date, and remaining battery time. It also allows for the entry of carbohydrates, insulin, and blood glucose (BG), with the option to view previously recorded data. Users were able to record specific physical activities, program reminders, and automatically record and transfer data, including step counts, to the mobile phone version of the diabetes diary. The smartwatch system can also be used as a stand-alone tool. Users reported usefulness, responded positively toward its functionalities, and also provided specific suggestions for further development. Suggestions were implemented after the feasibility study. Conclusions: The presented system and study demonstrate that smartwatches have opened up new possibilities within the diabetes self-management field by providing easier ways of monitoring BG, insulin injections, physical activity and dietary information directly from the wrist.

Functionalities and input methods for recording food intake: A systematic review

BACKGROUND Increasing healthcare costs related to lifestyle-related chronic diseases require new solutions. Research on self-management tools is expanding and many new tools are emerging. Recording food intake is a key functionality in many of these tools. Nutrition monitoring is a relevant method to gain an overview of factors influencing health. However, keeping a food diary often constitutes a challenge for a patient, and developing a user-friendly and useful electronic food diary is not straightforward. PURPOSE To gain insight into the existing approaches to recording food intake, and to analyze current functionalities and input methods. METHODS We searched digital libraries, vendor markets and social networks focusing on nutrition. Selection criteria were publications written in English, and patient-oriented tools that offered recording of food intake or nutrition. The system properties that we searched for were types of data, types of terminal, target population, and types of reports and sharing functionalities. We summarized the properties based on their frequency in the reviewed sample. RESULTS 31 publications met the selection criteria. The majority of the identified food recording systems (67%) facilitated entry of food type and the consumed quantity of food; 16% of the systems were able to record more than one type of data. The three most frequent target populations were people with obesity, diabetes and overweight. Mobile phones were used as terminals in 35% of the cases, personal computers (PCs) in 29%, and personal digital assistants in 23%. Only 10% supported both PCs and mobile phones. Data sharing was provided by 71% and reports by 51% of the systems. We searched for apps in Google Play and the Apple Store and tested 45 mobile applications that stored food intake data, of which 62% supported recording of types of food, 24% recording of carbohydrate intake and 15% recording of calorie intake. The majority of the mobile applications offered some kind of reports and data sharing, mainly via All of the tested social-network-enabled applications supported access from a personal computer and a mobile phone, search in a food database, reports, graphical presentation, listing of favorite foods, overview of own meals, and entering of consumed food type and quantity. CONCLUSION The analyzed apps reflected a variety of approaches to recording food intake and nutrition using different terminals--mostly mobile phones (35%), followed by PCs (29%) and PDAs (23%) for older studies, designed mainly for users with obesity (45%), diabetes mellitus (42%) and overweight (32%), or people who want to stay healthy (10%). The majority of the reviewed applications (67%) offered only input of food type and quantity. All approaches (n=31), except for two, relied on manual input of data, either by typing or by selecting a food type from a database. The exceptions (n=2) used a barcode scanning function. Users of mobile phone applications were not limited to data recording, but could view their data on the screen and send it via email. The tested web applications offered similar functionalities for recording food intake. The systems studied provided some degree of personalization: users can access some systems via PCs or mobile phones and they can choose among various types of data input content for recording food intake. Many functions, such as search in a food database, reports, graphical presentation, listing of favorite foods, and overview of the users own meals, are optimized to simplify the recording process and save time. Data sharing and reports are common features of the reviewed systems. However, none use the users recorded food history to make suggestions on new nutritional intake, during the food recording process. This may be an area for future research.

A Review of Mobile Terminal-Based Applications for Self-Management of Patients with Diabetes

Peer-reviewed studies of mobile terminal-based applications for self-management of patients with diabetes were reviewed. Databases of medical and engineering studies were searched for relevant publications, and 39 publications describing 28 studies were identified as examining feasibility, acceptability or effectiveness using empirical methods, preferably involving prospective users. Research methods, application design, and findings were summarized. The current status is that the key features of successful applications for diabetes management have not yet been clarified because of the difficulties in statistical comparison between studies and the limitations of each study. The importance of clarifying the key feature for enhancing motivation in long-term self-management of diabetes taking human-factor-engineering methods into account is discussed.

Propagation of program control: A tool for distributed disease surveillance

Abstract Purpose The purpose of the study was (1) to identify the requirements for syndromic, disease surveillance and epidemiology systems arising from events such as the SARS outbreak in March 2003, and the deliberate spread of Bacillus anthracis, or anthrax, in the US in 2001; and (2) to use these specifications as input to the construction of a system intended to meet these requirements. An important goal was to provide information about the diffusion of a communicable disease without being dependent on centralised storage of information about individual patients or revealing patient-identifiable information. Methods The method applied is rooted in the engineering paradigm involving phases of analysis, system specification, design, implementation, and testing. The requirements were established from earlier projects’ conclusions and analysis of disease outbreaks. The requirements were validated by a literature study of syndromic and disease surveillance systems. The system was tested on simulated EHR databases generated from microbiology laboratory data. Results A requirements list that a syndromic and disease surveillance system should meet, and an open source system, “The Snow Agent system”, has been developed. The Snow Agent system is a distributed system for monitoring the status of a populations health by distributing processes to, and extracting epidemiological data directly from, the electronic health records (EHR) system in a geographic area. Conclusions Syndromic and disease surveillance tools should be able to operate at all levels in the health systems and across national borders. Such systems should avoid transferring patient identifiable data, support two-way communications and be able to define and incorporate new and unknown diseases and syndrome definitions that should be reported by the system. The initial tests of the Snow Agent system shows that it will easily scale to national level in Norway.