=Paper=
{{Paper
|id=Vol-2515/paper3
|storemode=property
|title=TreC Diabetes: A Semantic Platform For Supporting The Self-management of Patients
|pdfUrl=https://ceur-ws.org/Vol-2515/paper3.pdf
|volume=Vol-2515
|authors=Mauro Dragoni,Claudio Eccher,Stefano Forti,Sara Puccini,Barbara Purin,Alessandro Valentini
|dblpUrl=https://dblp.org/rec/conf/semweb/DragoniE0PPV19
}}
==TreC Diabetes: A Semantic Platform For Supporting The Self-management of Patients==
https://ceur-ws.org/Vol-2515/paper3.pdf
TreC Diabetes: A Semantic Platform For Supporting
The Self-management of Patients
Mauro Dragoni, Claudio Eccher, Stefano Forti, Sara Puccini,
Barbara Purin, and Alessandro Valentini
Fondazione Bruno Kessler, Italy
{dragoni,cleccher,forti,spuccini,purin,avalentini}@fbk.eu
Abstract. The interest in designing a smart platform for supporting the self-
management of chronic disease significantly growth in the last years. One of the
chronic diseases that most attracted the attention of the research community is
diabetes. Such a chronic disease is worthy of investigation, concerning the real-
ization of smart platform, due to the possibility of (i) providing plans to patients
about the monitoring activities, (ii) knowing the parameters involved in the mon-
itoring process and the actions to trigger, and (iii) understanding possible barri-
ers impeding patients to fulfill the self-monitoring. In this paper, we present the
TreC-Diabetes system, a smart platform enabling the acquisition of patients data
and integrating real-time reasoning of data streams about glycemic index, food
intake, and performed sport activities. The platform is described and preliminary
lessons learnt from our deployment have been reported.
Keywords: Healthcare · Diabetes · Semantic Technology · Self-management.
1 Introduction
Clinical Decision Support (CDS) may be defined as the provision of person-specific
information, intelligently filtered, prioritized and presented at the right time to clini-
cians, patients, staff and others to enhance health and health care [3]. Outpatient dia-
betes CDS systems have been operative since 1983 [22], but meta-analyses indicate that
although outpatient diabetes CDS systems often improve test ordering and preventive
services, their impact on key diabetes care outcomes such as the control of glucose,
blood pressure, tobacco use or appropriate aspirin use has generally been marginal or
inconsistent [18].
On the contrary, there has been a major improvement in diabetes care delivery sys-
tems, in recent years. In the United States, recent national data indicate that the pro-
portion of patients who have simultaneously achieved adequate levels of glucose, blood
pressure, lipid and tobacco control and appropriate aspirin use has risen from 5% in
2002 to 25% nationally [1]. As care has improved, there have been dramatic decreases
Copyright 2019 for this paper by its authors. Use permitted under Creative Commons License
Attribution 4.0 International (CC BY 4.0).
2 Dragoni et al.
in the rates of heart attacks, strokes and end-stage diabetes complications due in large
part to improved remote diabetes care [4].
In this paper, we present our experience with the development of the TreC-Diabetes
CDS, a platform aiming to create a continuous link between clinicians and patients
for supporting the self-management of diabetes. Here, semantic technologies are used
for supporting real-time stream reasoning of information provided by patients to detect
possible critical situations and to inform clinicians about them.
The remainder of the paper is structured as follows. Section 2 discusses the main
work in the literature about CDS for managing diabetes. In Section 3, we present the
TreC-Diabetes project, while in Section 4, we show the modules of the architecture
we developed. Then, Section 5 discusses how the real-time stream reasoning has been
integrated into the system and in Section 6, we reported the lessons we learnt from this
experience. Finally, Section 7 concludes the paper.
2 Related Work
Many strategies have been shown in various studies to improve diabetes care, and there
is evidence that multiple intervention strategies improve diabetes care more than sin-
gle intervention strategies [4]. Diabetes CDS systems are generally compatible with
and may often be integrated with other concurrent diabetes care improvement strategies
such as pre-visit coaching of patients [11], opinion leader and other personalized edu-
cational interventions [20], case management [15], use of social media [17], or new and
more effective approaches to provider and diabetes patient education [21].
CDS can improve the quality of diabetic care by using reminders and monitor-
ing [14]. In chronic diseases like diabetes, documentation has an important role in
disease management. The availability of a population-based registry system can be
a solution for the health service providers, and a guidance to strengthen the diabetic
CDS. Nonetheless, short and long-term potential benefits of a CDS should be weighed
against the costs, because it needs the installation of the software and networking capa-
bilities, which requires planning. Therefore, the effective use of CDS in clinical settings
should be combined with changes in work processes such as changes in nursing roles
and provision of health care providers to encourage the adoption of CDS in the clinical
setting [6].
IT-based interventions along with usual care are associated with glycemic control
improvement in diabetic patients. In [12] the authors demonstrated that the usage of
CDS to support the management in primary care is feasible and the healthcare team con-
sidered it to be useful. A systematic review by [16] showed that information technology-
based interventions along with usual care resulted in glycemic control improvement
with various efficacy on clinical outcomes in individuals with diabetes. According to
the study presented in [19], remote monitoring appears to be a good alternative to cur-
rent therapy in diabetic care.
To the best of our knowledge, the TreC-Diabetes system is the first flexible system
combining the possibility of monitoring both clinical and lifestyle situation of a patient
to enable smarter reasoning on his/her data. The long-term objective of the platform is
to provide a full-fledged solution for supporting the self-management of diabetes (but
not limited to it) and at the same time to improve the lifestyle of patients.
TreC Diabetes: A Semantic Platform For Supporting The Self-management of Patients 3
3 The TreC-Diabetes Project
The development of the TreC-Diabetes platform was promoted by the Department of
Health and Social Policies of the Autonomous Province of Trento (PAT) in collaboration
with the Provincial Health Services Company (APSS) and carried out under the techni-
cal and scientific management of the Bruno Kessler Foundation (FBK). TreC-Diabetes
is a system to support self-care and to communicate between healthcare professionals
and diabetic patients, which APSS intends to use in an experimental phase within an
organizational model supported by technology and aimed at improving taking care of
the patient suffering from diabetes mellitus in the province. The fundamental principle
of the project is based both on the “Plan of the Cronicity” of the Ministry of Health and
on the agreement with the Regions, as the latter will have to define and promote new
organizational models for the management, even personalized, of the chronicity. In the
case of diabetes, personalized management is a systematic process focused on the inter-
action between doctor and patient, the frequent visualization of therapy results obtained
through easily usable digital solutions and the correction of therapy (both pharmacology
and non-pharmacology) earlier.
The general aim of the project is to improve the management and communications
between operators and patients affected by Type 1 and Type 2 diabetes mellitus through
the implementation of an organizational model for taking care of diabetic patients, sup-
ported by technology. The adoption of a specific technological platform, whose inter-
face for patients is represented by a mobile application and for clinicians by a web
dashboard, becomes the enabling factor to achieve three main study objectives:
– To integrate the TreC-Diabetes platform into the current organizational model.
– To intensify the clinician-patient and prevention relationship, being able to facilitate
communication between clinicians and patients through the exchange of objective
and subjective data, as well as a system of suggestions to the patient according to
an educational and not management logic of emergencies.
– Encourage empowerment and self-management of patients regarding their pathol-
ogy in everyday life.
4 System Architecture
The platform consists of a set of Web Modules composing the dashboard of clini-
cians and of Mobile Application Modules composing the tool available to patients.
We provide below the description of each module with a particular emphasis on the
knowledge-based component described in Section 5.
4.1 Web Modules (Physicians Dashboard)
Clinicians use a web dashboard that supports the remote supervision of the patient suf-
fering from diabetes. The dashboard consists of several components, in turn composed
of a series of functionalities. The dashboard components and their features are described
in more detail in the next subsections.
4 Dragoni et al.
Automatic configuration of patient’s mobile application This module support clinicians
concerning the manual registration, within the dashboard, of patient’s initial profile in-
formation. Here, the patient’s personal data are collected: information about his/her so-
cial status, therapies, history about the presence of complications or not, and lifestyle.
The clinician can manually insert also the care plan that the patient can view on his/her
mobile application. Such a care plan indicates the list of drugs that the patient must
take, the periodic measurements that the patient must take to keep his glycemic index
under control, and the schedule and results of laboratory tests that have to be performed
periodically. Figure 1 shows the mobile application configuration dashboard.
Display of Reports Clinicians visualize the patient’s data through two types of report:
– Periodic reports. With a fixed frequency or personalized according to the patient’s
clinical needs, clinicians receive reports containing information necessary for per-
forming a clinical evaluation of the patient’s health status. Each report contains:
profiling data, the results of laboratory tests, a summary questionnaire on the state
of recent health, and the data entered manually by the user in the mobile applica-
tion.
– Extraordinary reports. These reports contain messages related to the patient’s ill-
management of the pathology and received by e-mail from the clinician. The latter
indicates, during the activation of the mobile application, which events to consider
for triggering the generation of an extraordinary report.
Figure 2 shows an example of a monitoring report.
Activation of the Interactive Module The Interactive Module (MI) allows the clini-
cians to view the data entered by the user continuously and for a limited period. During
the activation of this module, the clinicians indicate the notifications he/she wants to
receive in real-time for the manual data entry by the patient (e.g. hypoglycemia and hy-
perglycemia events). Upon receipt of these notifications, it is a clinicians’ responsibility
to contact the patient for ascertaining his/her conditions and, possibly, to provide any
indications.
4.2 Mobile Application Modules (Patients)
The support to the self-management of patients and the possibility of sharing collected
data with clinicians is performed through a mobile application provided to each patient.
The mobile application is a tool to support diabetes management through a set of fea-
tures activated or not based on the clinicians’ decision. This mobile application enables
the possibility to act on seven specific areas of self-management (Healthy Eating, Being
Active, Monitoring, Taking Medication, Problem Solving, Reducing Risks, Health Cop-
ing) as indicated by the American Association of Diabetes Educators (AADE) 1 and,
consequently, to develop intervention strategies for promoting patient empowerment.
1
https://www.diabeteseducator.org/
TreC Diabetes: A Semantic Platform For Supporting The Self-management of Patients 5
Fig. 1. Internal page displayed after access to the dashboard. The mouse pointer icon shows the
reordering mode of the list of patients.
Fig. 2. Example of a graphic time display of data. The clinician can select the type of data he/she
wants to see represented. The icon with the eye in the top right corner allows you to hide / display
the single graphic.
6 Dragoni et al.
Log module The Log module is the base of the mobile application since it allows to
collect parameters and personal information of the patient through two different modes.
– Manual input of clinical data (such as blood glucose measurements). These param-
eters, such as weight and pressure, insulin therapy, drugs, and any symptoms, are
collected through structured interfaces implemented as diary functionality.
– Manual input of the patient through a dialogue interface. Such input has been fore-
seen in the interactions between the patient and the chatbot for the profiling of the
behaviors related to the specific AADE areas. Profiling consists of identifying the
level of health literacy, preparation for change and self-efficacy in each area, to
provide the most appropriate personalized intervention.
An example of this module is shown in Figure 3.
Display module This module contains the interfaces of the mobile application support-
ing the display of data entered in the diary by the user or sent by the system. Data are
shown through well-structured representations, i.e. graphics, text messages, and images.
An example of this module is shown in Figure 4.
Education module Education is performed through a mobile application in three differ-
ent ways.
– Contextual educational modules: educational modules that are automatically acti-
vated in response to critic patient pathology management events (e.g. when hypo-
glycemia/hyperglycemia is recorded based on the data entered).
– On-demand educational modules: educational modules that the patient can activate
on request to receive information related to the different aspects of diabetic pathol-
ogy (micro-learning).
– Additional modules: educational modules that the clinician can propose for the
patient on specific needs, e.g., the interactive modules developed according to an
educational and reflective logic in a “personal experiment” approach, or the carbo-
hydrate count in food.
Custom Feedback module This module deals with the processing of the parameters
and the data tracked by the user. Consequently, the system generates personalized feed-
back based on both the collected data and the user profile. The TreC-Diabetes mobile
application provides three types of personalized feedback:
– reminder messages/dialogues about actions suggested to the patient to perform. In
particular they are reminders related to the taking of drugs, glycemia measurement,
weight, pressure, medical examinations and laboratory tests, according to what is
foreseen by the treatment plan set by the clinician when the mobile application is
activated;
– personalized messages/dialogues to support the tracking and achievement of goals
(specific, measurable, achievable, realistic and time-based);
– motivational messages/dialogues to provide personalized suggestions and informa-
tion.
TreC Diabetes: A Semantic Platform For Supporting The Self-management of Patients 7
Fig. 3. Example of a list of data entered by Fig. 4. Example of available statistics for blood
the patient in the diary (Log module). glucose values.
Communication The Communication module allows the clinicians to start a chat with
the patient. Through this channel the clinicians can get more information on the pa-
tient’s health status and provide more precise and real-time information. The TreC-
Diabetes platform supports also chat groups, moderated by experts, where patients can
discuss together particular topics.
5 Reasoning Over Users’ Data Streams
The semantic component of the TreC-Diabetes platform is represented by the real-time
stream reasoner that is in charge of checking the data provided by patients for a set
of rules that clinicians integrated into the system. Rules are described by following
the ontological schema described in [8, 2]. The reasoning activity is performed by in-
voking the API of the HORUS.AI platform [10, 8, 9, 7, 13], a platform developed by
the TreC-Diabetes team for other healthcare initiatives that have been re-used in this
specific context. We implement reasoning by using RDFPro [5], a tool that allows
8 Dragoni et al.
us to provide out-of-the-box OWL 2 RL reasoning, supporting the fixed point evalu-
ation of INSERT... WHERE... SPARQL-like entailment rules that leverage the full
expressivity of SPARQL (e.g., GROUP BY aggregation, negation via FILTER NOT
EXISTS, derivation of RDF nodes via BIND).
We organize the reasoning in two phases: offline and online. The offline phase con-
sists of one-time processing of the static part of monitoring rules (examples of mon-
itoring rules are reported in Table 1). This is performed to materialize the ontology
deductive closure, based on OWL 2 RL and some additional pre-processing rules that
identify the most specific types of each rule individual. Whereas, during the online
phase, each time the reasoning is triggered (e.g., a piece of new information is entered),
the user data is merged with the closed ontology and the deductive closure of the rules
is computed. This process can be performed either on a per-user basis or globally on
the whole knowledge base. The result of this process is a new individual stored back in
the knowledge base containing all information about the detected critic situation.
Table 1 shows examples of rules integrated into the TreC-Diabetes platform.
Tags Rule (Values or Symptoms Timing Repeat
Pregnancy glycemia < 70 WAKEUP OR BEFORE-BREAKFAST SINGLE
Pregnancy glycemia > 95 WAKEUP OR BEFORE-BREAKFAST 3-DAYS
Pregnancy glycemia <= 50 NIGHT SINGLE
Pregnancy glycemia < 90 NIGHT 2-DAYS
Pregnancy glycemia > 140 90-MINUTES-AFTER-LUNCH 3-DAYS
Pregnancy ketones > 4 AND vomit ALWAYS SINGLE
Pregnancy ketones > 4 AND nausea ALWAYS SINGLE
Pregnancy ketones > 4 AND glycemia > 250 ALWAYS SINGLE
Pediatric, Adult glycemia < 70 WAKEUP OR BEFORE-BREAKFAST SINGLE
Pediatric, Adult glycemia > 200 WAKEUP 3-DAYS
Adult glycemia > 350 ALWAYS SINGLE
Pediatric, Adult glycemia > 300 WAKEUP SINGLE
Pediatric vomit ALWAYS SINGLE
Table 1. Excerpt of the rules integrated into TreC-Diabetes for supporting the real-time self-
management of patients.
The first column contains one or more tags identifying the kind of patients asso-
ciated with the rule. These tags are the same that can be found within the patients’
profiles. The second column contains the parameters that are monitored by the system.
Here, we have two kinds of parameters: the glycemic value (expressed in mg/dl) and
the symptoms that a patient can hold. Parameters are expressed through simple logic
expressions that are processed by the reasoner. The third column contains the timing
of a rule, i.e. when a rule has to be evaluated. The timing is expressed using keywords
that are processed by the reasoner. Each keyword corresponds to an individual modeled
within the back-end knowledge base containing datatype properties describing times-
tamp information exploited by the reasoning for knowing if the rule has to be verified
in a specific moment and which data as to be considered. Finally, the fourth column
indicates how many times a rule has to be evaluated. Most of the rules are evaluated
TreC Diabetes: A Semantic Platform For Supporting The Self-management of Patients 9
at a SINGLE stage, i.e. when a new data is provided by a patient, only those data are
considered. Instead, other rules, even if violated after a specific event, do not generate
a new alert, but they are evaluated again for a certain number of times. For instance, a
rule with a REPEAT value of 3-DAYS means that a new alert is generated only if such a
rule is violated for three days in a row. As for the timing column, also the keyword con-
tained within the repeat column correspond to individuals of the back-end knowledge
base containing datatype properties describing timestamp information about when and
how many times the rule has to be evaluated.
6 Lessons Learnt
The TreC-Diabetes experience allowed us to collect several lessons that will drive the
improvement of the overall system.
Developing more effective provider and patient interfaces The provider interfaces pro-
vide estimates of absolute risk reduction related to potential clinical action in six do-
mains (e.g. blood pressure, lipids, glucose, smoking and BMI). Patient interfaces are
even more challenging because of the wide variation in health literacy and numeracy re-
lated to culture, education, language and other factors. Such interfaces need much more
development and will need to be tailored to the preferences and needs of various patient
subgroups. The patient interfaces were designed for low-literacy and low-numeracy pa-
tients and some providers give the provider interface to selected patients. A reasonable
option may be to display CDS in various formats to meet the needs of a broad spectrum
of patients and providers with very different learning styles and literacy.
Moving from disease-centered to patient-centered CDS At many primary care encoun-
ters, diabetes is only one of many chronic or acute problems that need to be addressed.
In the primary care world, it will not be feasible to have a CDS system for each of
the many chronic diseases or clinical domains. Rather, the goal is necessary to cre-
ate a patient-centered CDS system that identifies, for each patient at a given point in
time, all the evidence-based actions that may be of benefit. Thus, some sort of priori-
tization function is necessary to streamline the process and keep provider and patient
attention focused on actions with the greatest potential benefit to the patient. Patients
with diabetes may also benefit from better identification and management of comor-
bid conditions such as depression, heart failure, coronary heart disease, arthritis and
lung disease. What is not apparent is how to accomplish accurate prioritization across
multiple clinical domains.
Incorporating patient-reported data and data from wireless devices into CDS systems
CDS algorithms now incorporate lab tests, vital signs, allergies, current treatment, co-
morbidities, distance from goal and clinical state, as well as other EHR data. However,
most do not yet incorporate patient-reported data (e.g. symptoms of hypoglycemia,
screening questions for depression) or data that are collected outside the encounter and
can be transmitted wirelessly to the EHR or an associated website. The addition of such
data, including data on physical activity from wearable devices or self-reported dietary
10 Dragoni et al.
intake, could considerably expand the scope of diabetes-related CDS systems. For ex-
ample, home glucose data could be processed through algorithms that suggest specific
insulin adjustments in response to certain glucose test patterns or the cardiovascular
benefits of lifestyle changes such as more physical activity could be compared with the
benefits of certain pharmacological interventions to reduce cardiovascular risk. In set-
tings with access to pharmacy fill data, assessment of medication adherence may also
be possible and further enhance the ability of providers and patients to make informed
decisions about medication management.
Expanding the applications of CDS technology Evidence-based algorithms that operate
within CDS systems can be modified rapidly in response to advances in knowledge,
new consensus guideline recommendations, or the introduction or removal of drugs
from the care-path. This is a major paradigm shift in clinical care. Advances in secure
communication of data between EHRs and websites open up new possibilities for large-
scale and efficient regional or national approaches to CDS, provided large numbers of
providers and care systems can agree on the content of treatment algorithms.
An exciting future application of EHR-linked CDS is to create a map of care quality
at the provider level by mapping the clinical decision space for diabetes care in previ-
ous work to clinics or individual data that can be ranked alongside their peers, such
as the percentage of patients with uncontrolled diabetes with an insulin start; timely
intensification of lipid, glucose or blood pressure medications.
7 Conclusions
In this paper, we presented the TreC-Diabetes platform, a system designed for sup-
porting (i) the self-management of patients suffering from diabetes, (ii) their real-time
health status, and (iii) the work of clinicians for controlling them remotely. The compo-
nents of the deployed platform have been described with a focus on the real-time stream
reasoning component that is in charge of detecting critic situations. Finally, lessons
learnt from our experience have been reported to highlight the main aspects that will
drive the technological improvement of the platform.
References
1. Ali, M.K., Bullard, K.M., Saaddine, J.B., Cowie, C.C., Imperatore, G., Gregg, E.W.:
Achievement of goals in us diabetes care, 1999–2010. New England Journal of Medicine
368(17), 1613–1624 (2013)
2. Bailoni, T., Dragoni, M., Eccher, C., Guerini, M., Maimone, R.: Healthy lifestyle sup-
port: The perkapp ontology. In: Dragoni, M., Poveda-Villalón, M., Jiménez-Ruiz, E. (eds.)
OWL: - Experiences and Directions - Reasoner Evaluation - 13th International Workshop,
OWLED 2016, and 5th International Workshop, ORE 2016, Bologna, Italy, November 20,
2016, Revised Selected Papers. Lecture Notes in Computer Science, vol. 10161, pp. 15–23.
Springer (2016). https://doi.org/10.1007/978-3-319-54627-8 2, https://doi.org/10.1007/978-
3-319-54627-8 2
3. Berner, E.S.: Clinical decision support systems: state of the art. AHRQ publication 90069
(2009)
TreC Diabetes: A Semantic Platform For Supporting The Self-management of Patients 11
4. Bodenheimer, T., Wagner, E.H., Grumbach, K.: Improving primary care for patients with
chronic illness: the chronic care model, part 2. Jama 288(15), 1909–1914 (2002)
5. Corcoglioniti, F., Rospocher, M., Mostarda, M., Amadori, M.: Processing billions of RDF
triples on a single machine using streaming and sorting. In: SAC. pp. 368–375. ACM (2015)
6. Crosson, J.C., Ohman-Strickland, P.A., Cohen, D.J., Clark, E.C., Crabtree, B.F.: Typical elec-
tronic health record use in primary care practices and the quality of diabetes care. The Annals
of Family Medicine 10(3), 221–227 (2012)
7. Dragoni, M., Bailoni, T., Eccher, C., Guerini, M., Maimone, R.: A semantic-enabled platform
for supporting healthy lifestyles. In: Seffah, A., Penzenstadler, B., Alves, C., Peng, X. (eds.)
Proceedings of the Symposium on Applied Computing, SAC 2017, Marrakech, Morocco,
April 3-7, 2017. pp. 315–322. ACM (2017). https://doi.org/10.1145/3019612.3019835,
https://doi.org/10.1145/3019612.3019835
8. Dragoni, M., Bailoni, T., Maimone, R., Eccher, C.: Helis: An ontology for supporting healthy
lifestyles. In: Vrandecic, D., Bontcheva, K., Suárez-Figueroa, M.C., Presutti, V., Celino,
I., Sabou, M., Kaffee, L., Simperl, E. (eds.) The Semantic Web - ISWC 2018 - 17th In-
ternational Semantic Web Conference, Monterey, CA, USA, October 8-12, 2018, Proceed-
ings, Part II. Lecture Notes in Computer Science, vol. 11137, pp. 53–69. Springer (2018).
https://doi.org/10.1007/978-3-030-00668-6 4, https://doi.org/10.1007/978-3-030-00668-6 4
9. Dragoni, M., Bailoni, T., Maimone, R., Marchesoni, M., Eccher, C.: HORUS.AI - A
knowledge-based solution supporting health persuasive self-monitoring. In: van Erp, M.,
Atre, M., López, V., Srinivas, K., Fortuna, C. (eds.) Proceedings of the ISWC 2018 Posters
& Demonstrations, Industry and Blue Sky Ideas Tracks co-located with 17th International
Semantic Web Conference (ISWC 2018), Monterey, USA, October 8th - to - 12th, 2018.
CEUR Workshop Proceedings, vol. 2180. CEUR-WS.org (2018), http://ceur-ws.org/Vol-
2180/paper-14.pdf
10. Dragoni, M., Rospocher, M., Bailoni, T., Maimone, R., Eccher, C.: Semantic technologies for
healthy lifestyle monitoring. In: International Semantic Web Conference (2). Lecture Notes
in Computer Science, vol. 11137, pp. 307–324. Springer (2018)
11. Greenfield, S., Kaplan, S., Ware Jr, J., Yano, E., Frank, H.: Patients participation in medical
care: Effects on blood sugar control and quality of life in diabetes. Journal of General Internal
Medicine 3, 448–457 (1988)
12. Maia, J.X., de Sousa, L.A.P., Marcolino, M.S., Cardoso, C.S., da Silva, J.L.P., Alkmim,
M.B.M., Ribeiro, A.L.P.: The impact of a clinical decision support system in diabetes pri-
mary care patients in a developing country. Diabetes technology & therapeutics 18(4), 258–
263 (2016)
13. Maimone, R., Guerini, M., Dragoni, M., Bailoni, T., Eccher, C.: Perkapp: A general purpose
persuasion architecture for healthy lifestyles. Journal of Biomedical Informatics 82, 70–87
(2018). https://doi.org/10.1016/j.jbi.2018.04.010, https://doi.org/10.1016/j.jbi.2018.04.010
14. McGlynn, E.A., Asch, S.M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A., Kerr, E.A.:
The quality of health care delivered to adults in the united states. New England journal of
medicine 348(26), 2635–2645 (2003)
15. Norris, S.L., Nichols, P.J., Caspersen, C.J., Glasgow, R.E., Engelgau, M.M., Jack Jr, L.,
Isham, G., Snyder, S.R., Carande-Kulis, V.G., Garfield, S., et al.: The effectiveness of dis-
ease and case management for people with diabetes: a systematic review. American journal
of preventive medicine 22(4), 15–38 (2002)
16. Riazi, H., Larijani, B., Langarizadeh, M., Shahmoradi, L.: Managing diabetes mellitus using
information technology: a systematic review. Journal of Diabetes & Metabolic Disorders
14(1), 49 (2015)
17. Ronda, M.C., Dijkhorst-Oei, L.T., Rutten, G.E.: Patients experiences with and attitudes to-
wards a diabetes patient web portal. PloS one 10(6), e0129403 (2015)
12 Dragoni et al.
18. Roshanov, P.S., Fernandes, N., Wilczynski, J.M., Hemens, B.J., You, J.J., Handler, S.M.,
Nieuwlaat, R., Souza, N.M., Beyene, J., Van Spall, H.G., et al.: Features of effective com-
puterised clinical decision support systems: meta-regression of 162 randomised trials. Bmj
346, f657 (2013)
19. Siriwardena, L.N., Wickramasinghe, W.S., Perera, K.D., Marasinghe, R.B., Katulanda, P.,
Hewapathirana, R.: A review of telemedicine interventions in diabetes care. Journal of
telemedicine and telecare 18(3), 164–168 (2012)
20. Smith, D.H., Kramer, J.M., Perrin, N., Platt, R., Roblin, D.W., Lane, K., Goodman, M., Nel-
son, W.W., Yang, X., Soumerai, S.B.: A randomized trial of direct-to-patient communication
to enhance adherence to β-blocker therapy following myocardial infarction. Archives of in-
ternal medicine 168(5), 477–483 (2008)
21. Sperl-Hillen, J., OConnor, P.J., Ekstrom, M.H.L., Rush, W.A., Asche, M.S.E., Fernandes,
M.O.D., Apana, M.D., Amundson, M.G.H., Johnson, P.E., Curran, M.D.M.: Educating res-
ident physicians using virtual case-based simulation improves diabetes management: a ran-
domized controlled trial. Academic medicine: journal of the Association of American Med-
ical Colleges 89(12), 1664 (2014)
22. Thomas, J.C., Moore, A., Qualls, P.E.: The effect on cost of medical care for patients treated
with an automated clinical audit system. Journal of medical systems 7(3), 307–313 (1983)