Mon, Nov 19, 2018

Q: Can you describe the daily routine with the MG system?

A: The following story explains by giving an example of enrollment and routine use of the MG system. The story is about a fictional patient called Montse who develops diabetes during pregnancy (this condition is known as gestational diabetes, or GDM for short). The GDM version of the MobiGuide system helps Montse and her medical team to monitor and manage her condition.

  1. Enrollment to MobiGuide:

Montse is a pregnant woman of 34 suffering from gestational diabetes. Her pregnancy was monitored in primary care until they diagnosed gestational diabetes and she was referred for monitoring and treatment to the hospital. In the hospital, she receives education on her disease, different types of therapies, blood glucose control and nutritional aspects.

In the hospital, all kind of data about Montse is collected and stored in the EMR to perform (extended) diagnosis and determine the following steps in her treatment. For example, the Oral Glucose Tolerance Test (OGTT) performed in primary care is also stored in the hospital electronic medical record (EMR).

Jim is an endocrinologist at the Spanish hospital. Jim and Montse meet in the hospital for a regular visit. Jim discusses with Montse the progression of her gestational diabetes. He indicates that she is eligible for using the MobiGuide patient guidance system. He explains to her the advantages and disadvantages and Montse decides she is willing to use the system. After explanation, Jim and Montse sign the informed consent forms, and continue to enroll Montse in the Mobiguide System.

Jim logs-in to the care provider interface and starts the enrollment process of Montse. This process consists of four main steps: (i) initialization of PHR record and coupling to EMR, (ii) assignment to computerized clinical guideline and personalization, (iii) activation of the patient mobile system and (iv) starting of the patient guidance.

  1. Assignment to clinical guideline and personalization:

Jim continues to the second step of the enrollment process. Based on the visible OGTT results, Jim verifies the GDM diagnosis of Montse. He assigns her to the GDM computerized clinical guideline and further personalizes it towards Montse’s personal situation by augmenting her PHR record, some specific elements that are specified below. The system retrieves knowledge for further personalization.

Jim and Montse together explore all her personal context (e.g. asks her for regular situations she is in. They select two personal contexts: regular & on-holiday, and match them to the routine and semi-routine diet and schedule context defined during computerized clinical guideline customization, and confirm the pre-defined effect on the medical treatment. These mappings are stored in Montse’s personal health record (PHR) of MobiGuide.

They define Montse’s preferences regarding her number and timing of daily meal intakes, and indicate which meals should be associated with blood glucose (BG) measurements, for which of those should reminders be sent. They leave the default valid (of 30 minutes) that indicates how many minutes before the measurement  the reminder should be sent. This duration can be set either on the care giver UI or on the patient's UI. They specify that she normally takes three meal intakes: breakfast at 8:00, lunch at 12:00 and diner at 19:00, but during holiday, she likes to shift everything by 1 hour.  These preferences are stored in Montse’s PHR.

Jim continues to the third step of the enrollment process. Jim selects a pre-packaged set of Smartphone and appropriate monitoring devices (for GDM this is a glucometer and physical exercise detection monitor) from his cabinet and he first explains to Montse how to use it using the application's demonstration mode.

Jim provides Montse with the MobiGuide phone and devices, her username and activation code.

Together they activate the MobiGuide system using the smartphone application. Montse starts the app, which asks her for her username and activation code. This information is checked by the system, and Montse is asked to register her personal pin-code.

Montse is asked to select her current context; she presses a button on the application to indicate that she is currently in her ‘Regular’ context.

The MobiGuide application indicates: “Congratulations, you are enrolled in the MobiGuide system. From now on, you will receive recommendations”.

  1. Daily routine:

Montse is living her daily life. According to her measurement plan, she is measuring BG levels regularly (4 times, every day in personalized hours). Today she is having lunch in her work restaurant. She knows that she has to measure BG after eating her lunch hence she uses the glucometer to perform the measurement and takes the MG smartphone from her purse in order to record the result.

Montse logs-in to the MG app, navigates to the BG measurement screen measures and enters her BG level. In the last 3 days, BG levels have been normal. The MG system detects this compliance pattern and acknowledges Montse’s good BG measurement compliancy with the following message: “Congratulations, you are following recommendations about blood glucose monitoring very well.”

The building is quite massive and she has flaky wireless internet coverage. However, when she goes online the blood glucose and compliancy data is also stored into the PHR. 

  1. Low compliance detection:

A week passed. During this week, Montse is working on an important report. As a result she sometimes forgets to monitor BG. Additionally, she indicated already once that she did not follow diet prescriptions. Today she is having lunch at the park and she takes out her smartphone to measure BG data and enter diet information.

Montse logs-in to the MG app, she navigates to the diet page and indicates she did not eat according to her diet prescriptions. She navigates to the BG measurement page and enters her BG, which is 115 and is normal. The MG system detects a non-compliancy pattern with two times in 3 days that Montse didn't comply with diet and didn't report several BG measurements during those 3 days. MG notifies the care provider on the situation.

In the hospital, during his inspection of his patients, Jim logs-in to the caregiver interface and opens Montse’s record and sees there is a recommendation asking for acknowledgement regarding the non-compliancy and suggesting that with a click of a button he can send Montse an educations reinforcement message. He reads the recommendation and decides to send the educational reinforcement message to Montse: “Remember that it is very important that you keep following diet recommendations and measuring blood glucose frequently”. 

  1. High BG levels falsely detected:

The next morning Montse receives a recommendation at her specified breakfast notification time to measure her BG. She logs-in to the MG app and enters a 193 mg/dL glucose level. The system recognizes that this value is pretty high (compared to her previous measurements) and this might indicate a possible error in the entered value. The system asks Montse to re-enter her BG measurement.

Montse directly sees her mistake; she was a bit sleepy this morning and she by accident entered a wrong value. She wanted to input 93 mg/dL. Luckily she gets the opportunity to correct. The system recognizes this more likely value, which is within normal range. The correct data is stored in the PHR.

  1. Good metabolic control:

Montse recovered from a small period of non-compliancy. During the past month, she was very consistent in sending BG measurements. Because BG levels were normal along the period, the clinical context of good metabolic control is true for Montse. The system detects this context and sends a recommendation to the Jim to indicate that it might be possible to decrease the frequency of monitoring BG levels.

Jim logs-in the caregiver interface and looks at the received recommendation. He acknowledges the proposed changes in treatment. The MobiGuide system sends new projections to her mobile phone with the new scheduling.

After the mobile decision-support system analyzing it, Montse receives a message to indicate that her treatment is changed and that she can measure blood glucose levels twice a week instead of every day: “Your blood glucose levels show an appropriate glycemic control; you can reduce the number of daily measurements to measure blood glucose twice a week” (3-4 times a day but only twice a week).