Continuing care introduction
The Centers for Disease Control and Prevention (CDC) estimated that, in the United States, the number of people diagnosed with diabetes increased from 5.8 million in 1980 to 15.8 million in 2005; and as of 2009, 23.6 million people have diabetes.
More than most chronic diseases, diabetes often requires behavioral and medication changes supported by frequent feedback and support from care providers. Technological advances have made it possible for people with diabetes and other chronic illnesses to increase the amount of communication with their care providers and family members using Internet-based software products. This increase in communication between caregivers and patients represents more of a "continued care" model of healthcare that improves patient health.
Recent studies have shown that an increase in patient-healthcare practitioner (HCP) interaction is linked to the successful treatment and management of diabetes. When managing diabetes using software products that modify behavior, patients generally enjoy better health than those who do not. In fact, the Diabetes Control and Complications Trial (DCCT) study at the National Institute of Health (NIH) demonstrated that individuals with Type 1 diabetes who maintain normal blood glucose levels can slow the onset and progression of eye, kidney, and nerve diseases caused by diabetes.
Other clinical studies at Georgetown University Medical Center and the Boston Veteran's Administration Hospital (conducted by researchers from Brigham and Women's Hospital and Harvard Medical School), have demonstrated that the consistent use of MCT-Diabetes results in a significant reduction in average blood glucose levels as measured by HbA1C.
In addition to improving patient health, continuous care using Internet-based software products benefits physicians, employers, and insurers. For example, employers will notice a reduction in expenses and increased productivity from healthier employees, and insurers will notice a decrease in medical costs resulting from diabetes and its associated complications. According to the National Council on Aging, every 1% decrease in HbA1C results in an annual 4 - 30% decrease in medical costs, depending on the patient's initial HbA1C level.
Diabetes use case
Collaborative software products enable individuals with chronic illnesses, such as diabetes, and their care providers to communicate frequently across the Internet. One such product, MCT-Diabetes from MyCareTeam, Inc. (see Resources), is a behavior modification tool that allows individuals with diabetes and their care providers to collaborate and monitor glucose levels along with other key data related to diabetes across the Internet. Because MCT-Diabetes data and reports are accessible over the Internet, care providers and family members, with permission, can monitor a child's glucose data while a child is away at college, and an elderly parent living in Florida can be easily monitored by a grown child who may live in Boston.
MCT-Diabetes facilitates a daily commitment to self-management through the balance of lifestyle and medication. With MCT-Diabetes, patients can transmit their blood sugar readings directly from their glucose meters to a secure database using the Internet.
Figure 1. Glucose meter upload capability
Once the data is stored, physicians, care providers, and family members can use the tool to monitor glucose levels, understand lab values, and examine the effects that exercise and diet have on a patient's health. In addition to monitoring glucose levels, MCT-Diabetes includes carbohydrate counting, meal planning, exercise tracking (see Figure 2), as well as the logging of medication, blood pressure and vital signs information.
Figure 2. Personal meal log and carbohydrate look-up
All of the data that is collected by MCT-Diabetes is available to specifically-chosen members of the patient's care team, as shown in Figure 3:
Figure 3. TotalView: Summary of all data
Continuing care for diabetes live demonstration
The live demonstration presented at the HIMSS (Healthcare Information and Management Systems Society) interoperability event illustrated an end-to-end architecture connecting devices in the home with provider systems. The scenario builds on a patient, Charley, who is a 52-year-old male with adult-onset diabetes mellitus (type II diabetes). Charley also struggles with his weight and is considered to be overweight to obese. His physician has recommended dietary changes and wants to monitor his weight, as well as his daily glucose readings. Charley has been provided with a connected glucometer and weight scale that enable him to take readings in the comfort of his own home multiple times a day. From Charley's perspective, it's simple. He gets up in the morning, takes his readings, and continues his day. But if you take a look at the supporting architecture, the story doesn't end there.
Figure 4 provides a high-level view of the supporting architecture necessary to capture the events from Charley and to provide information to the appropriate members of Charley's care network. This architecture spans a variety of technologies, specifications, and standards.
Figure 4. Continuing care for diabetes demonstration architecture
- Devices are physical sensors that the patient interacts with at home. In the demonstration scenario, the patient, Charley, has two personal health monitoring devices, a Roche glucometer and an A&D weight scale. These devices take the physical readings from the patient and send them to the device manager. In the scenario, the devices communicated using standards-based protocols adhering to the Continua specifications (see Resources) and guidelines for interoperability.
- The Device Manager is the computer that the physical devices connect to. The Device Manager contains the software, reads information from the device, and translates it, using Web services, to a remote monitoring service. A Device Manager can take many forms, ranging from something as powerful as a PC or laptop to a mobile phone or embedded-edge computer. In the demonstration scenario, a Eurotech Zeus was used to collect readings in the home and transmit them to the upstream Remote Monitoring Service.
- The Remote Monitoring Server (RMS) in this scenario was built on top of the IBM Sensor Event Platform. This platform provides a collection of software components enabling persistence of the events, complex event processing, and correlation of events, an application server to support the user interface, and notification systems, as well as the interfaces supporting broader system integration with provider applications.
- Provider applications cover a range of offerings that compliment the healthcare delivery for Charley, enabling his information to be shared with a PHR (Personal Health Record), EMR (Electronic Medical Record) systems supporting his physician, or disease management systems. Each of these provider applications demonstrates a different integration point with the sensor event platform. In the case of Google Health, the RMS server was responsible for translating the HL7 Personal Healthcare Monitoring Report (PHMR) to the Continuity of Care Record (CCR) supported by Google Health. The integration point with Greenway Medical Systems demonstrated the sharing of health record information through the Integrating the Healthcare Enterprise (IHE) Framework. The integration allowed the RMS server to submit an aggregate of readings to the IHE repository, making the readings available to Greenway Medical Systems. In a third scenario, a set of data services was made available from the RMS platform that provided a way for MyCareTeam to query using standards-based Web services and to retrieve the HL7 PHMR.
This section dives a little deeper into the demonstration and focuses on the integration point between the RMS and MyCareTeam. Due to time constraints and the breadth of the demo, the development teams had to quickly adapt to enable the integration between the two systems. DB2 pureXML (see Resources), HL7, XML, and XQuery provided a set of technologies, standards, and products that served as accelerators for the development. This section discusses how these technologies fit into the demo.
The patient portal, illustrated in Figure 5, provides a sample reference mash-up on the RMS platform. The portal enables several key aspects for tele-health professionals. A tele-health professional can log in and view their active patients, as well as the latest readings for that patient. In addition, the user interface can be extended to allow tele-health professionals to drive a series of actions. For this demonstration, a mechanism was provided to allow a tele-health nurse to select a patient and publish his readings to a DB2 pureXML database. These patient readings are specified in a standard HL7 format and stored in the XML column of a database.
Figure 5. Reference patient portal
DB2 pureXML and DB2 Universal Services
DB2 pureXML provides support for persisting XML documents directly to a column in the database, including the ability for applications to leverage XQuery to query the contents of the table. This made it extremely easy to persist the published records without the need to create the HL7 model in a traditional relational structure. In this demonstration, the RMS implemented server-side components to insert the new records using standard JDBC calls.
The next step was to provide an interface that MyCareTeam could call with Web services to retrieve specific data about a patient. This is where the DB2 Universal Services available on developerWorks came into play (see Resources). We chose these services for a number of reasons. They provided working code that exposed Web services (SOAP & REST) to enable a consumer to run XQueries against the published set of patient documents. The services also provided a test application that MyCareTeam could use independently to check their interface. Figure 6 provides a high-level view and samples of the data passed on the interface. The MyCareTeam software was able to use a relatively simple XQuery statement to retrieve the HL7 document based on the demo patient ID to update their data repository. Through standards-compliant interfaces and data models, such as HL7, XML and XQuery, the MyCareTeam was able to demonstrate integration with the RMS and to present the new sets of readings in the MyCareTeam portal.
Figure 6. RMS/MyCareTeam overview
Technologies for collaborative continuous care
Technologies used in the demonstration
One of the technologies described earlier is the pureXML feature of DB2 9. This feature provides the ability to natively store documents or messages in XML in a database. In this demo, the HL7 Personal Health Monitoring report is stored. In the past, the only options were to store the XML as a BLOB or to shred the elements in the XML into relational tables. Neither of these older methods is ideal.
With the BLOB method, the XML cannot be queried, nor can just a portion be returned to an application. The entire XML message must be exported. The application then has to parse and query the XML message to obtain just the information needed to send to the user or report tool.
With the shred method, extra time is required to design and map the elements to the database tables, and to parse and load all the elements into the multiple tables with no guarantee that the XML message could be reconstructed. The extensibility of the XML is lost, as the entire database design must be redone to accommodate the addition of new elements or a format change to any elements.
One advantage of pureXML is that it allows you to store the message in XML format in its native hierarchical form, saving substantial time in the initial stages of design and development, as well as during each query, as the parsing or reconstruction phase has been eliminated. Plus, if the XML message is updated, no additional database design or application changes are needed.
DB2 is now a hybrid database in that it has the ability to store relational data and XML data in a single database, even in a single table. DB2 has been extended so that it understands XML, how to parse it, efficiently store it, query it using either XQuery or SQL/XML, update it using the XMLTransform function, and return to the application either the entire XML message or just the portions you care about.
Universal Services, also mentioned earlier, are used to easily enable the XML messages stored in DB2 to be accessed. The Universal Services are a set of database operations, including insert, update, delete, and query, exposed as Web service operations. The services allow users to query and modify XML data stored in the pureXML column through REST or SOAP. Using these services help access XML in an SOA application. These services are available as a free software download for any customer to use and modify as they wish (see Resources).
Related technologies and initiatives
IBM Lotus Mobile Portal Accelerator: This software provides an easy, cost-effective way to deliver portal-based content and applications to virtually all mobile devices. Patients can use their device of choice to retrieve last updates on readings and reports. Its intelligent Multi-channel Server adapts the content for each mobile device based on the specific device characteristics and capabilities, as defined in the device repository. Data and content providers can therefore 'write once' and render personalized Web content quickly across over 6,000 different mobile device types. Mobile Web portals extend access to portal services and data from many of the approximately three billion mobile devices in use to help enterprises maximize business opportunities.
IBM Lotus Sametime: Instant messaging can be used in support of healthcare collaboration. In an article entitled "Lotus Sametime and DB2 pureXML supporting healthcare collaboration" (developerWorks, February 2009), an example is provided of an end-to-end XML architecture that allows information encoded in Health Level 7 (HL7) Clinical Document Architecture (CDA) XML documents to be stored in the same format in a pureXML database, exchanged in the same format utilizing Web services, and visualized in the same format using IBM Lotus Sametime Connect Client. A prototype Sametime plug-in for instant messaging clients can be used to access and display XML patient data stored in a database through Universal Services. The prototype plug-in enables healthcare providers and others to share patient information through instant messaging.
IBM WebSphere Sensor Event Platform: This software enables home healthcare providers to capture data from in-home device managers, which serve as a collection point for a variety of in-home medical devices such as glucometers, weight scales, medication packs, and blood pressure cuffs. It includes the ability to easily implement rules to identify significant events, and also provides standards-based connections into Electronic Medical and Personal Health records systems and disease management applications such as MyCareTeam. The activities of the Continua Health Alliance make a standards-based approach, such as the one enabled by WebSphere Sensor Events, practical across a growing array of Continua-compliant medical devices.
(See the Resources section for more information regarding these technologies and initiatives.)
This article introduced some results concerning continuing care for diabetes. In particular, studies have shown that increased patient Health Care Practitioner interaction, especially more personalized interactions, increases patient frequency of blood glucose monitoring. Providing software that encourages personalized interactions improves diabetes monitoring. The contribution of Web-based technologies and associated initiatives, such as the MyCareTeam software, to share data is significant. In addition, the diabetes monitoring demonstration described in this article used standard specifications in the area of healthcare from HL7, IHE, and Continua, and in the area of XML from the W3C, such as XQuery. An XML store, DB2 pureXML, accessed through Universal Services, was used to easily store and manipulate monitoring information. The demonstration illustrated the first steps towards building a Web-based infrastructure for continuing care in the home.
- MyCareTeam: Learn more about MyCareTeam, disease management software for diabetes patients.
- Continua Health Alliance: Learn more about Continua Health Alliance, a non-profit, open industry coalition of healthcare and technology companies.
- DB2 pureXML: Get more information about, a hybrid XML and relational store from IBM.
- "Universal Services for pureXML using Data Web Services" (developerWorks, August 2008): Enable DB2 pureXML columns to be accessed through Web service operations.
- "IBM Lotus Sametime and DB2 pureXML supporting healthcare collaboration" (developerWorks, Feb 2009): Follow a healthcare scenario based on an end-to-end XML architecture.
- IBM Lotus Mobile Portal Accelerator: Learn more about this content adaption product that helps enterprises and service providers deliver portal content to a broad range of mobile devices.
- IBM WebSphere Sensor Events: Learn more about this product that delivers services supporting sensor integration.
- developerWorks Information Management zone: Learn more about Information Management. Find technical documentation, how-to articles, education, downloads, product information, and more.
- Stay current with developerWorks technical events and webcasts.
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- DB2 Express-C 9.7: Download DB2 Express-C 9.7, a no-charge version of DB2 Express database server for the community that includes pureXML.
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