Introduction 1 2 1 1 3 4 5 6 7 8 9 10 Greater patient self-efficacy Greater satisfaction with care, continuity, provider, quality of health outcome 1c Improved diet and body weight control Lowered cholesterol Lowered perception of diabetes intrusiveness Improved quality of life Less depression Decreased incidence of diabetic complications. 8 9 1 10 The purpose of this paper is to review the patient's and the health care professional's needs in an Internet-based diabetes management solution and to examine how these needs are addressed in practice. An evaluation framework was constructed by grouping the requirements of an Internet-based diabetes management solution into 5 categories: Monitoring, Information, Personalization, Communication, and Technology. Two of the market leaders (myDiabetes and LifeMasters) were selected and evaluated to illustrate the use of the framework. Methods diabetes chronic disease internet technology AND diabetes internet diabetes technology chronic disease internet chronic disease technology Table 1 The abstracts of the articles retrieved by the searches were screened for relevance by the authors. The relevant articles were reviewed in order to compile a comprehensive list of requirements for an Internet-based diabetes management solution. These requirements were identified on the following basis: No interdependence between requirements Requirements can be assessed as present or not present Equal implementation effort required to satisfy the requirements. 11 12 User defined parameter-Patient Identify User, Retrieve Parameters Save Parameters Table 2 www.myDiabetes.com www.lifemasters.com Table 2 Table 3 Yes No Figure 1 Figure 2 Bedtime Statistical Analysis 13 14 Results Evaluation Criteria Table 2 Monitoring 4 15 16 17 1 4 1 Effective patient monitoring is not limited to the collection of health data, it also requires a multidisciplinary approach, proactive outreach, and feedback. Multidisciplinary Approach 18 19 20 Proactive Outreach 21 22 Feedback 22 1 23 Information 24 25 Pull Model The pull model relies on the patient retrieving the information he or she seeks. Two pathways are provided to this end. The patient can retrieve documents by navigating through the Web site or can retrieve information with a search engine. Navigation requires a clearly-defined information structure. This is effectively implemented with a hierarchical structure that users can follow to retrieve information of increasing level of detail. Navigation should be facilitated by a clear on-screen indication of the user's location in the information hierarchy. Search engines allow users to search for documents based on keywords. Search engine technology is capable of cataloguing documents based on several criteria. In its simplest form, documents will be catalogued based on their text. Therefore, a search will yield all the documents containing the word that was searched for. However, a successful implementation of a search engine will categorize documents based on several criteria such as topic, author, date, and relevance. Users can then use these criteria to refine their searches. Push Model The push model involves presenting the information to the patient who has opted to receive it. Relevant information could include new research or newly-released drugs for patients who have specified an interest. Interest can be formally expressed by the patient or can be inferred by the system in an effort to personalize the service (see the "Personalization" section of "Evaluation Criteria"). Information delivery in the push model can be implemented in several ways. Patients can be presented with the relevant information upon logging into the system. Alternatively, technologies such as mobile phones and pagers can be used for delivery. A successful Internet-based management system will implement both models of information delivery. Personalization Self-management Plan 17 26 17 17 personal action plan 27 17 Language and Ethnicity 28 haves have-nots 29 Communication Communication Between Health Professional and Patient 30 31 32 33 Community Creation Community creation is based on a many-to-many communication channel compared with the one-to-one communication that occurs between health care professional and patient. Community support is a fundamental aspect of self-management of disease. Diabetes patients benefit from discussing topics that concern management of the disease, anxiety as to what the future holds, and interpersonal and social relationships. 34 35 1c Technology The complex network of human and machine relations involved in managing diabetes via an Internet-based system has strong implications for the design of such a service. Security 23 Authentication Identification of users is a crucial step in gaining access to the system. Users are granted access to data based on their security profile. For example, only the treating physician can modify a specific patient's blood glucose ranges. Therefore, authentication is both the identification of a user (usually with a combination of username and password) and the enforcement of the security profile. Naturally, user identification is required for more-advanced functions like personalization as mentioned earlier. Encryption All data transmitted between a patient and the system must be secure. Several encryption algorithms exist, with different strengths and speeds. Generally speaking, most Web servers can establish secure communication links using Netscape's Secure Socket Layer (SSL), which is de facto the Internet standard. Recently, 128-bit encryption has been made available worldwide. Any transmission of patient data should be encrypted at the highest level. Usability and User Acceptance 36 1 1 Reliability and Availability One of the great advantages of the Internet is that it allows users to access systems anytime and from almost anywhere. This results in a need for systems to always be operational, that is, without downtime. Zero downtime (or close to it) requires fault-tolerant systems. Several technical solutions exist both at the software and hardware level. It is outside the scope of this paper to examine all the solutions; however, it is reasonable to expect an Internet-based diabetes management system to not require downtime for maintenance and to have a fault-tolerant hosting environment. Open Platform Open technologies are based on nonproprietary standards; therefore, a system can be built using technologies from multiple vendors. This is particularly useful for future expansions or medications to accommodate for increased scalability and functionality requirements. An Internet-based diabetes management system should be based on an open platform, particularly for data exchange. Open standards for data representation such as the eXtensible Markup Language (XML) are being adopted by multiple industries. Consequently, a system built using XML will be able to interface with multiple systems and devices. The same system could deliver its services via multiple devices (Internet, mobile phone, handheld computer, etc.) effectively making the Internet open platform the standard. Evaluation of 2 Existing Services www.myDiabetes.com www.lifemasters.com Yes Yes No Table 3 The technology criteria registered the lowest agreement (60%-80%). The different levels of technical expertise of the evaluators may explain this difference. The Personalization criteria also showed lower levels of agreement between evaluators. This is due to the different interpretations of the criteria between evaluators. Personalization remains a difficult dimension to quantify and evaluate. The quality-of-information agreement levels were also low (60%-80%). Both sites displayed the HON code logo and stated that they subscribed to the HONCode principles. However, neither site was HON registered, although - as of December 14, 2001 - LifeMasters was under review process. 37 Graphical Representation Figure 3 The results of the evaluation indicate that LifeMasters is a more-complete solution than myDiabetes in all dimensions - except Information, where both sites were equivalent. This is primarily due to LifeMaster's inclusion of the health care professional in the disease-management cycle. On the other hand, myDiabetes is uniquely interfaced with the patient and is quite good in providing a communication channel for community creation, however, communication with health care professional is lacking, hence the lower score than LifeMasters. Discussion 38 24 39 24