Qualitative Research
Article
Type 1 diabetes self-management: developing a web-based telemedicine application
Haleh Ayatollahi, PhD 1 ,
Mostafa Hasannezhad, MSc 1 ,
Hedieh Saneei Fard, MD2,
Mehran Kamkar Haghighi, MSc 1
Abstract Background: Self-management skills are essential for patients with diabetes mellitus to minimise the risks of compli- cations from their condition. The aim of this research was to develop a web-based application for self-management of type 1 diabetes, suitable for use by patients, their carers and physicians. Method: The study was comprised of two phases, the first being analysis of the kind of information and capabilities required by potential users of the system. Based on the results derived from the first phase of the study, the system prototype was designed and then evaluated using the ‘think aloud’ method and a standard questionnaire. The application was designed for use by patients, their carers and physicians. Patients could enter the level of blood glucose, insulin and activities on a daily basis, and physicians were able to supervise a patient’s health status from a distance. Results: Users were generally satisfied with the final version of the system. People with a wide range of literacy skills were able to use the system effectively. Conclusion: Patients or their carers could use the web-based application as a log book by entering the level of blood glucose and insulin doses on a regular basis, and as an educational resource to improve self-management skills. Physicians could use the system at any time convenient to them to support patients by giving medical advice. Further research is needed to report the effectiveness of the system in practice.
Keywords (MeSH) type 1 diabetes mellitus; chronic disease; disease management; self-management; telemedicine; Iran; health information management
Background
Diabetes mellitus is a condition that occurs when the pan-
creas is unable to produce sufficient levels of the glucose
regulating hormone insulin, or when the body’s cells cannot
accurately respond to it (Smeltzer et al. 2008; Shrivastava,
Shrivastava & Ramasamy 2013). Globally, diabetes is one of
the most prevalent endocrine diseases, which causes about 4
million deaths annually. In the USA, the cost of healthcare
for a patient without diabetes is about 2,560 USD annually,
while for a patient with diabetes, it is about 11,744 USD
(Harmel & Mathur 2004; Pazhoohi & Khoshniyyat 2010).
The World Health Organization (WHO) and the Amer-
ican Diabetes Association (ADA) have classified diabetes
into four groups: type 1, type 2, gestational diabetes mellitus
(GDM) and diabetes due to other causes. Type 1 diabetes or
insulin dependent diabetes, which comprises 10% to 15% of
total cases of diabetes, is an autoimmune disease where the
body destroys the insulin-producing cells, and eventually no
insulin is produced. Patients with this type of diabetes must
be provided with subcutaneous insulin injections, and the
number of patients hospitalised due to type 1 diabetes is
5.3 times more than patients who are hospitalized due to
other diseases (Ragnar 2006; Smeltzer et al. 2008).
As diabetes is a lifelong disease, it is necessary to train
diabetic patients in self-management techniques to mini-
mise its probable risks (Bodenheimer et al. 2002). Clearly,
people with diabetes have differing levels of knowledge,
social support, self-efficiency, motivation, disease cer-
tainty, and individual capabilities for self-management
activities (McDonald et al. 2004; Sousa et al. 2005). Con-
sequently, they have different information needs for man-
aging their illness, and such information must be provided
1 Department of Health Information Management, Iran University of
Medical Sciences, Tehran, Iran 2
Paediatric Endocrinology & Metabolism, Imam Hossein Hospital, Shahid
Beheshti University of Medical Sciences, Tehran, Iran
Accepted for publication August 26, 2015.
Corresponding author:
Haleh Ayatollahi, Department of Health Information Management, Iran
University of Medical Sciences, Tehran, Iran.
Email: ayatollahi.h@iums.ac.ir
Health Information Management Journal 2016, Vol. 45(1) 16–26 ª The Author(s) 2016 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1833358316639456 himj.sagepub.com
by an expert as effectively as possible. For example, insulin
injections, a healthy eating style tailored for diabetics and
physical activities are important for managing diabetes and
patients must learn how to maintain a balance between
these factors (Bodenheimer et al. 2002). Increases in blood
glucose level may cause a number of complications; there-
fore, a patient with diabetes must learn how to control the
level of blood glucose through adjusting insulin dosage
(Mulcahy et al. 2003).
It is critical that patients with diabetes, particularly type 1
diabetes, have access to continuous healthcare services (Sim-
mons et al. 2007). However, in developing countries financial
and human resources are limited (Debussche et al. 2009) and
only 50% of patients with diabetes are referred to hospitals
and healthcare centres to receive these services. Face-to-face
education plans and training for self-management, designed
to empower patients in managing their illness, are often insuf-
ficient in meeting these requirements (Simmons et al 2007;
Debussche et al 2009). Furthermore, due, for example, to
remote distance or transportation costs, it can be impossible
for some patients to attend hospitals and have continuous
access to healthcare services. The use of information technol-
ogy and provision of online training has been suggested as a
method of regular and continuous education (Zaali 2006).
The Internet has become a powerful medium for teaching the
elements of a healthy lifestyle as well as improving patients’
knowledge about their disease. It is expected that an appro-
priate online application would facilitate the process of care
and improve the self-sufficiency of patients or their families
in the management of the disease (Izquierdo et al. 2003;
Wantland et al. 2004).
The literature review showed that many studies have
been undertaken to investigate the benefits of the Internet
as an information resource for patients with diabetes
(Wantland et al. 2004; McMahon et al. 2005; Lee et al.
2007; Moore et al. 2008; Roek et al. 2009). Some of these
benefits are: providing patients with recommendations,
reminders, educational information and online support;
improving communications between patients and health-
care providers; and empowering patients to be able to man-
age their disease (Izquierdo et al. 2003; Wantland et al.
2004; Moore et al. 2008; Silk et al. 2008). Some studies
showed that while the annual cost of traditional treatment
for a patient with diabetes is between 300 and 1000 USD,
managing these patients using web-based applications is
about 50 USD per each patient (Zaali 2006). Nevertheless,
most people who are using the Internet as an information
resource still prefer face-to-face communication with their
healthcare providers (Jennings et al. 2009).
Most studies published in this area have focused on web-
based diabetes self-management education programs (Chau
et al. 2012; Yu, Parsons, Mamdani et al. 2014); designing a
recommender system and an e-learning course for patients
with diabetes (Hidalgo et al. 2014); designing a dialogue-
based application to improve knowledge of patients with
diabetes about their illness (Weymann et al. 2013; Wey-
mann, Härter & Dirmaier 2013); and the use of mobile
phones in recording health data and communicating with
healthcare providers (Frøisland, Arsand & Skårderud 2012;
Nes et al. 2012). Few studies have presented an interactive
web-based application for diabetes self-management as a
telemedicine approach to support patients (Yu, Parsons,
Hall et al. 2014; Siminerio et al. 2014). It should be empha-
sised that although the use of the latest technology in
empowering self-management is valuable, in many devel-
oping countries telemedicine and even simple web-based
applications are still new and require more attention. How-
ever, in most of these countries the Internet is available to
different age groups (children and adolescents) and can
provide them with high level of support for self-
management at a very low cost (Debussche et al. 2009).
Currently, in Iran, there are about seven million patients
with diabetes and among them about 500,000 suffer from type
1 diabetes. The age range of patients with diabetes is 10 to15
years less than the age range of similar patients in the devel-
oped countries (Pazhoohi & Khoshniyyat 2010). According
to the latest report issued by the Ministry of Health, 700
million USD dollars should be spent to manage the disease
and to treat the patients annually. This is a huge amount of
money in which indirect costs have not been included (Este-
qamati 2004). Web-based interventions have the potential to
improve diabetes care and self-management (Yu, Parsons,
Hall et al. 2014) and the technological features can help
patients to receive online support (Zhou et al. 2014). As
patients demand access to personalised healthcare, web appli-
cations should be designed to meet users’ specific needs (Nij-
land et al. 2011), and to achieve this, end-users must be
involved in the design process (McCurdie et al. 2012). More-
over, there are a number of individual and context-specific
factors that influence the use of the system and simply adopt-
ing the existing systems might not be a desirable approach
(Fichman, Kohi & Krishnan 2011). Therefore, the researchers
intended to design a web-based application to support patients
with type 1 diabetes. This was the first time that such an
application had been developed in this country. It is expected
that by using such an application, many direct and indirect
benefits, such as improving the health status of patients with
diabetes and saving costs, can be gained.
Method
This study was completed in 2013 and consisted of two
main phases. Initially, a survey study was undertaken to
determine what kind of information and capabilities are
required by the users of the application. In the second
phase, the application was developed based on the results
derived from the first phase, and the initial usability testing
was conducted. The setting of the research was the endo-
crine clinic in a teaching hospital.
Participants
The initial plan was to develop an application that could be
used by both groups of users, namely patients and their
endocrinologists. In the first phase of the study, Group 1
included 30 participants (7 patients with type 1 diabetes,
and 23 parents who took care of their children with type 1
diabetes). The parents of patients under 15 years of age
Ayatollahi et al. 17
were asked to take part in the study. Group 2 included 15
endocrinologists, paediatric endocrinologists and their fel-
lows who worked in different teaching hospitals. The
method of convenience sampling was used to select
patients and endocrinologists.
The endocrine clinic was responsible for implementing
diabetes screening programs and more than 100 patients
were visited monthly by the endocrinologists in this clinic.
In the second phase of the study, 15 system users (5 endo-
crinologists, 5 patients and 5 parents), who were interested
in taking part in the usability testing of the website, were
invited to attend the clinic and evaluate the usability of the
application.
Data collection instrument
To determine the information needs of the users, a ques-
tionnaire called ‘Information Needs Assessment Question-
naire-INAQ’ was designed based on the criteria suggested
by the American Diabetes Association (ADA) (Nes et al.
2012), Iranian Diabetes Association (IDA) (Delavari 2004;
Pazhoohi & Khoshniyyat 2010), and by reviewing other
related materials (Lee et al. 2007; Jennings et al. 2009;
Nordfeldt et al. 2013). The questionnaire included 32
closed questions and was divided into four main parts:
required data elements related to patient’s demographic
information; clinical information; physician’s supervision;
and required system capabilities. There were two possible
answers for each question; ‘necessary’ or ‘unnecessary’. At
the end of each part, there was an open-ended question that
asked the participants to suggest further data elements or
system capabilities that might not have been considered in
the questionnaire. The content and the face validity of the
questionnaire were checked by the experts. The reliability
was confirmed using a statistical test (KR-20 ¼ 0.74). In order to collect data, the questionnaires were given to
a nurse who worked in the endocrine clinic. As she was
responsible for taking a clinical summary of patients, she
could easily identify patients with type 1 diabetes. She
asked patients or their parents to complete the question-
naire. The participants were also asked whether they were
interested in taking part in the second phase of the study.
The same questionnaire was distributed among the endo-
crinologists by the researcher (MH) who attended the clinic
personally to ask physicians to complete the questionnaire.
As the number of endocrinologists was limited in the clinic,
they referred the researcher (MH) to their colleagues who
were working in other teaching hospitals.
The usability of the system and users’ satisfaction with
the interface was evaluated using the standard Question-
naire for User Interaction Satisfaction (QUIS) version 5.5
provided by the University of Maryland (Alexandru 2010).
The 9-point Likert scale questionnaire included five parts
(27 questions), overall reaction to the software (6 ques-
tions), screen design and layout (4 questions), terminology
and systems information (6 questions), learning (6 ques-
tions), and system capabilities (5 questions). The question-
naire was translated and its face validity was checked.
According to the literature, the reliability of the
questionnaire was (a ¼ 0.94) (Alexandru 2010). This ques- tionnaire was completed by 15 users (patients, parents and
physicians) who were invited to attend the clinic and use
the prototype of the system.
Data analysis
Initially, the data collected in the survey study were ana-
lysed as follows. To decide which data elements should be
included in the application, a rule was set by the research-
ers. According to this rule, the data elements selected as
‘necessary’ by at least 60% of the participants (both
patients and endocrinologists) were considered important
to be included in the application. To analyse the data col-
lected from the usability testing, the Likert scale was
divided into three levels: ‘weak’ (1-3), ‘average’ (4-6) and
‘good’ (7-9). Mean values were calculated for different
parts of the questionnaire, and were reported for patients,
parents and physicians separately. The final results were
reported based on the three levels mentioned above.
System design and usability testing
The prototype of the system was designed using ASP. NET
programming language. To evaluate the usability of the
system, the ‘think aloud’ method was used initially. This
is a cheap, robust, flexible, convincing and easy to learn
method in which participants are asked to use the system
while verbalising their thoughts as they move through the
interface (Nielsen 2012). This method has also been used in
other studies to evaluate the usability of a system (Qiu &
Yu 2007). In this research, the prototype of the system was
run on a personal computer (PC) in a private room in the
clinic. One of the researchers (MH) initially introduced the
system to 5 participants (3 patients and 2 physicians). He
explained the study objectives to the participants and col-
lected their informed consent. The participants were asked
to perform the experimental tasks while verbalising what-
ever they saw, did, and felt when performing these tasks.
During each session, MH took field notes about the parti-
cipants’ performance and comments. All sessions were
audio-recorded and the duration of each session was about
30 minutes. The participants’ comments were applied to the
final version of the system. Similar to the previous stage,
the final version of the system was run on a PC in the clinic.
Then, a number of users (5 patients, 5 parents, 5 physicians)
were asked to work with the system and evaluate it using a
standard questionnaire (QUIS). Generally, the website was
refined in a number of cycles to confirm the requirements
of users. A research flow diagram is presented in Figure 1.
Ethics approval
Ethics approval was obtained from the university research
ethics committee. Participation was voluntary and the
respondents could opt out of any phases of the study at any
time. All participants were fully informed about the project
and signed a written consent form before taking part in the
study. Patients’ and physicians’ identities were kept
18 Health Information Management Journal 45(1)
confidential throughout the process of data collection and
system usage.
Results
Participants’ demographic information
In total, 7 patients and 23 parents took part in the study. The
age range of patients was between 15 and 30 years, and
most of them were female (n ¼ 4, 57%). The age range of parents, who took care of children aged under 15 years with
type 1 diabetes, was between 20 and 50 years, and the
highest frequency was related to mothers (n ¼ 18, 78.3%). Most of the endocrinologists who took part in this
study were men (n ¼ 9, 60%) and their age range was between 31 and 58 years.
Required data elements and system capabilities
After data analysis, the data elements identified as ‘neces-
sary’ by at least 60% of the participants were selected to be
included in the application. For example, regarding blood
glucose control, all items were found necessary to be
included in the website (Table 1).
Interestingly, items, such as the contact number of a
patient’s relatives, patient’s address, place of birth, mar-
riage status, father’s name, and the identification number
were not found necessary by most of the participants. Table
2 shows the required data elements and capabilities of the
website found necessary by at least 60% of the participants.
Prototype
The prototype of the system was designed in accordance
with the results of the first phase. The method of prototyp-
ing has some advantages, such as reducing the time and the
cost of the design process, preparing an initial version of
the system for making modifications with low cost, higher
efficiency in the final version, and more compatibility with
the users’ requirements.
As the users of the application were patients or their
parents and endocrinologists, the system was designed for
both groups. The system was stand alone and all informa-
tion must be entered manually. At the time of the study,
there was no link between this system and other health
information systems, for example clinic health records.
However, apart from receiving advice from the endocrinol-
ogists, patients could use it as a diabetic patient’s logbook.
The first page of the system was a login page and included a
general description about the system, rules and regulations,
and some information about national diabetes associations.
New users had to click and complete a registration form
which included their name, surname, date of birth, sex,
telephone number, email address, username and password.
When completing the registration form, the type of user
was specified. After logging into the system, the user could
see the relevant pages based on the type of the user deter-
mined in the previous step.
Features for patients
The final version of the system included eight links for
patients: recording new data; editing profile; reading edu-
cational materials and information about how to manage
diabetes; viewing changes in the level of blood glucose and
insulin in a table and a graph; contacting the endocrinolo-
gists; contacting the website administrator; and changing a
password. To record new data, patients could choose a date
Development of the website
Literature review and designing a questionnaire for requirements
analysis
Requirements analysis Patients (n=7) Parents (n=23)
Physicians (n=15)
Designing the system prototype
Evaluation of the website using the ‘think aloud’ method
Patients (n=3), Physicians (n=2)
Evaluation of the website using the usability testing method
Patients (n=5), Parents (n=5), Physicians (n=5)
Website refinement
Website refinement
Planning to introduce the website to other endocrinology clinics
Figure 1. The research flow diagram.
Ayatollahi et al. 19
to enter the level of blood glucose, insulin, and their activ-
ities manually. The level of blood glucose and activities
could be reported five times a day and the insulin rates
(NPH and regular) could be reported twice a day (Figure 2).
The educational material was developed based on the
needs assessment study conducted in the first phase. This
part was intentionally provided in a simple form, so that
children or adolescents with a low level of literacy could
understand it. To make it attractive, animations and images
were used in different parts, which included some informa-
tion about diabetes, how to control the level of blood glu-
cose, insulin types and the method of injection, a healthy
diet, diabetes complications, and suggested exercises and
activities.
Features for endocrinologists
For endocrinologists, the system included five links: view-
ing a list of patients who had updated their records or con-
tacted their physician; viewing patients’ blood glucose,
insulin rate and activities in a table along with full infor-
mation about the patient (Figure 3); viewing the graphs of
changes in blood glucose and insulin rate (Figure 4); pre-
scribing and medical advice; and changing a password.
Physicians could first log into the system whenever it
was convenient for them, and would see a list of their
patients, identifying those who had entered their recent
data. Next to the patient’s name, there was a link to show
further information and changes in the blood glucose, insu-
lin rate and activities in a table and a graph. Finally, phy-
sicians could see and answer questions asked by patients. In
addition, physicians could also be informed about new
messages via their email. Therefore, the system helped
them to monitor patients’ health status without visiting
them in the clinic, and they could supervise their patients
from a distance.
Usability testing
To ensure the system worked as intended and met users’
requirements, the usability of the system was tested using
the ‘think aloud’ method and a standard questionnaire
(QUIS). According to Lyles, Sarkar and Osborn (2014),
technology-delivered diabetes education and support inter-
ventions should be evaluated using standard usability test-
ing. To evaluate the usability of the initial design, the
prototype of the system was run on a PC in the clinic and
5 participants (3 patients and 2 physicians) were asked to
Table 1. Required data elements for blood glucose control.
Diabetes self-management Questionnaire items Respondents Necessary % Unnecessary %
Mean (%) Necessary
Mean (%) Unnecessary
Blood glucose control
Recording blood glucose level Physicians (n ¼ 15) 15 (100) 0 100 0 Patients (n ¼ 7) 7 (100) 0 Parents (n ¼ 23) 23 (100) 0
Training on blood glucose monitoring
Physicians (n ¼ 15) 15 (100) 0 98.5 1.5 Patients (n ¼ 7) 7 (100) 0 Parents (n ¼ 23) 22 (95.6) 1 (4.4)
Training on the use of a glucometer
Physicians (n ¼ 15) 14 (93.3) 1 (6.7) 97.8 2.2 Patients (n ¼ 7) 7 (100) 0 Parents (n ¼ 23) 23 (100) 0
Table 2. Required data elements and features for the website.
Data group Data elements
Patient’s demographic information First name, last name, age, sex, height, weight and contact number Patient’s clinical information Last HbA1C hemoglobin, total daily insulin injections, blood glucose test frequency (daily),
hypoglycemia episodes (weekly), hypoglycemic convulsion frequency (monthly), number of hospitalization, number of emergency visits (every 6 months), number of specialist visits (in 6 months)
Diabetes self- management
Blood glucose (BG) level Recording BG levels (five times a day), training on BG monitoring and the use of a Glucometer Insulin injection Time and the amount of insulin injection, Insulin titration information, information about
different types of insulin, required actions in insulin overdose Nutrition Nutritional information, necessary information about the food components Diabetes complications Information about controlling hypo/hyperglycemic episodes, information about diabetic
convulsion, caring for foot, eye, kidney and other organs Activity The amount of patient’s daily activities, type of activities Other required
information Information about diabetes-related scientific associations, endocrinology and metabolism
institutes and related clinics Physicians’ supervision Checking BG values, BG testing schedule for each patient, insulin injection dosing,
supervising patient’s diet, recommendations and medical advices for patients Required capabilities of the system Displaying date/time of data entry, recording time of BG testing, displaying a graph of
insulin and BG level changes, displaying the patient’s previous data (BG, insulin and activity rate), tele-consultation with physician via e-mail
20 Health Information Management Journal 45(1)
Figure 2. Features for patients – Reporting blood glucose, insulin rate and activities.
Figure 3. Features for endocrinologists – Demonstration of patients’ blood glucose, insulin rate and the amount of activities in a table.
Ayatollahi et al. 21
work with the system and explain their points of view. This
‘think aloud’ method helps the system designer to modify
the prototype based on the users’ needs and make it more
efficient. In this study, the verbal expression of users’
thoughts was recorded using a digital voice recorder and
each person used the system for about 30 minutes. For
example, patients suggested that the system should be able
to give a message registering successful data entry. They
were also interested in viewing a graph of changes in their
blood glucose and insulin rate, and wanted to know how to
contact the system administrator when they had a question
or suggestion about the system. Physicians suggested that
all messages sent by patients should include time and date,
and if a patient had just asked a question, it should be
highlighted in the list of patients. It is also important for
users to be able to change their passwords. Having modi-
fied the system based on the users’ perspectives, 15 users
were invited to attend another session in the clinic to work
with the system and to evaluate its usability using a stan-
dard questionnaire. In each session, only one participant
attended. The results of the usability testing of, and users’
satisfaction with, the system are presented in Table 3.
According to the results, the mean values for patients,
parents and physicians were between 7 and 9 in different
areas of assessment, indicating that the users were rela-
tively satisfied with the system. From the physicians’ point
of view, ‘terminology and system information’ (8.40 + 0.89), and from parents’ and patients’ point of view ‘overall
reaction to the software’ had the highest mean values. The
Figure 4. Features for endocrinologists – Changes in a patient’s blood glucose.
Table 3. Usability testing of, and users’ satisfaction with, type 1 diabetes self-management website.
Mean + SD
Assessment areas Mean + SD (5 physicians)
Mean + SD (5 patients)
Mean + SD (5 parents)
Overall reaction to the software
8.20 + 0.83 8.40 + 0.89 8.00 + 1.00
Screen design and layout
7.90 + 1.07 8.20 + 0.83 7.80 + 0.83
Terminology and system information
8.40 + 0.89 7.40 + 0.54 7.80 + 0.83
Learning 7.80 + 0.83 7.20 + 0.83 7.60 + 1.14 System capabilities 7.60 + 1.14 8.00 + 1.00 7.80 + 0.83
22 Health Information Management Journal 45(1)
lowest mean values were related to the system capabilities
(7.60 + 1.14) from physicians’ perspectives and the sys- tem learnability (7.20 + 0.83) from patients’ and parents’ perspectives (7.60 + 1.14).
Discussion
The use of the Internet and web-based systems have many
advantages for patients and healthcare providers. These
systems can help patients to receive online education and
to ask questions, for example, by sending emails. Health-
care providers can also use web-based systems to obtain
information about patients’ health status and to set proper
care plans for them without any concerns about distance
and time limit (Lee at al. 2007). Another benefit of such an
intervention is to increase patient engagement, which in
turn can help to improve quality of care, especially primary
care (Dubenske et al. 2010). In diabetes, like many other
chronic diseases, many problems faced by patients can
potentially be prevented by an organised care plan, educa-
tion, and timely supervision (Hee-Sung 2007). As a result, a
web-based application can be a useful tool to control their
health status in a timely manner (Wantland 2004; Montori
et al. 2004). In a study conducted by Lee et al. (2007), a
web-based self-management education system was devel-
oped and its effectiveness was evaluated. Their study
showed that web-based education could help patients to
control their blood glucose level and could improve their
diabetes self-management skills. Lee et al. (2007) also
introduced this type of education as the best tool for pro-
viding continuing care.
Generally, self-management of diabetes is influenced by
a number of individual, social, and clinical factors and each
individual may have unique requirements and challenges to
the appropriate management of their own care. Therefore,
personalised self-management interventions are needed to
meet different individuals’ requirements (Cassimatis,
Kavanagh & Smith 2014). While in some studies theoreti-
cal frameworks of self-care and self-efficacy have been
used to design a website for self-management (Yu, Parsons,
Hall et al. 2014), in the current study, users’ requirements
were initially investigated in order to be able to design a
useful system. The results of the first phase showed that
most of the data elements suggested by the national and
international diabetes associations were found necessary by
the users (patients, parents and physicians) and recom-
mended to be included in the system. Similarly, the per-
spectives of patients, parents, and physicians showed close
correspondence regarding the required capabilities of the
system.
According to Dougherty et al. (2014), telemedicine can
be used effectively to promote the health status of adoles-
cents with diabetes. In the current study, the researchers
aimed to develop a telemedicine application for patients
and physicians to be able to communicate electronically.
Therefore, the system features were not limited to educa-
tional resources. In a similar study, Jennings et al. (2009)
developed a virtual clinic to facilitate self-management of
diabetes for patients who used an insulin pump. Using this
system, patients were able to communicate with diabetes
specialists who were not necessarily their own physicians.
In addition, the communication sessions were conducted
via the site’s asynchronous discussion forums. However,
in the current study, users were able to consult their own
physicians. As the website was password protected, each
physician was able to review their own patients’ informa-
tion, and as a result, patients’ privacy and information con-
fidentiality were respected.
As noted previously, only information related to type 1
diabetes could be entered into the system and there was no
link between this system and other patient heath records;
therefore, it cannot be considered as a personal health
record (PHR). The PHR is owned, controlled, and managed
by the patients and is not limited to operating systems or
devices. Moreover, the interoperability of data between
diverse systems is one of the main characteristics of PHR
(Kahn, Aulakh & Bosworth 2009). As a result, apart from
being a telemedicine application, the system designed in
this study can be considered an electronic logbook to help
patients with type 1 diabetes to keep an online record of
their health status.
The literature review indicated that in some studies
related to the use of web-based systems for diabetes self-
management, the systems were not evaluated by the users
(Roek et al. 2009; Ko et al. 2010; Lyles, Sarkar & Osborn
2014). However, in the current study the system was eval-
uated by patients, parents and physicians. Findings indi-
cated that most users were satisfied with the system and
the overall reaction was quite positive, which showed it had
been accepted in the initial stage. Similarly, Lee et al.
(2007) used a questionnaire to evaluate users’ satisfaction
with their system. These researchers found that 45% of
users were satisfied with the interface of the system, 40%
of users were neutral and 15% had negative views.
According to Debussche et al. (2009), providing educa-
tion to enable patients to self-manage their disease is still a
challenge in some developing countries, and in particular,
more field study is needed to address the continued require-
ments and demands of individuals with chronic diseases
like diabetes (Shrivastava, Shrivastava & Ramasamy
2013). It is possible to introduce web-based systems to
those countries which have affordable internet access. In
developing countries, due to the shortage of specialists and
healthcare resources in different geographical areas,
patients have to be in a long waiting list to visit a physician.
The resulting delay in receiving treatment or obtaining
advice from a physician could affect a patients’ condition
(Debussche et al 2009). However, the use of web-based
systems can facilitate access to healthcare services at the
point of need. Furthermore, the accessibility of information
about the patients’ blood glucose, insulin, and physical
activities can help physicians to make better decisions
regarding the patient’s condition.
Implementing such systems in developing countries
might engender some challenges (Alajmi, Almansour &
Househ_2013). For example, it might be difficult to con-
vince specialists and patients to use the system as a replace-
ment for a face-to-face consultation if, for example, the
Ayatollahi et al. 23
specialists are busy visiting patients and may not be able to
spend time using the system (Khanal et al. 2015). It seems
that receiving adequate support from the national diabetes
associations can help to introduce the system’s benefits,
and this would facilitate the process of system implemen-
tation and usage. At the time of this study, it was not clear
to what extent the system will be adopted by patients and
their physicians. Therefore, after introducing the system to
other clinics, further research is needed to investigate users’
attitudes and the likelihood of usage in a bigger sample
size.
Limitations
Although it was the first time in this country that such a
web-based system was designed to support patients with
diabetes, the current study had some limitations. First, the
number of patients and physicians recruited in the study
was limited. As the researchers aimed to develop a new
system, rather than to extrapolate the results to a larger
population, it seems that using such a small group of parti-
cipants does not necessarily influence the system design
process. In fact, the main aim of recruitment was to involve
a number of potential users to be able to design a useful
system specifically for them.
Due to the time and resource constraints, the researchers
focused on providing a system specifically for patients with
type 1 diabetes. As paediatric patients with type 1 diabetes
and their parents might be less experienced in regard to
self-management activities, the system was designed to
be as simple as possible in order to support this group of
users in particular. However, the application could be
expanded by adding more relevant information for other
types of diabetes. The system could also be improved by
adding more information about patients’ diet and calorie
intake.
In terms of the usability testing, the application needs to
be evaluated on a larger scale (by patients, parents and
physicians) to show how usable it is from users’ perspec-
tives more generally. In this case, the researchers would
require an opportunity to improve the system by introdu-
cing it to other clinics or diabetes associations. In addition,
the clinical effectiveness of this system was not evaluated
in this study due to resource restrictions. Conducting pre/
post-implementation studies would help to evaluate the
impact of the system on the health status of patients with
type 1 diabetes.
Conclusion
Although a large part of caring for those with chronic dis-
eases such as diabetes is undertaken by the patients them-
selves or their carers, the use of information technology is
recommended as an effective tool to facilitate patients’
access to their health information and to improve their
self-management skills. The application designed in the
current study was an example of a web-based system that
could be easily be made available by connecting to the
Internet. For example, patients or their carers could use it
as a log book by entering the level of blood glucose and
insulin doses on a regular basis. They could also learn more
about the disease and self-management skills by reading
the educational part of the system. Physicians could use
the system at any time convenient to them to support
patients by giving medical advice. The significance of this
research was the simplicity and the transparency of the
system developed in terms of the contents, meaning that
it was useable even by children and others who were able to
use the Internet yet had low literacy skills. Moreover, the
use of the Internet made it available and affordable to dif-
ferent age groups, thus system developers and users might
not be faced by major financial or technical obstacles in
setting up such a scheme. Further research is needed to
evaluate the usability of the system and to report its effec-
tiveness in terms of improving self-management activities.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
work was supported by Iran University of Medical Sciences
[Grant Number 592]. The authors declare that they have no con-
flict of interest.
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