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: [email protected]

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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