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3. 42 Nutrition Food Meal USDA Help Exchanges Planning Food Values Figure 9 Nutrition Exercise Level three 43 d Control Mechanisms The ENTER key activates the menu selection The ESC key returns the user to the Main Menu 4 3 2 Meal Planning A third level menu selection item that provides access to four fourth level menu selection items Figure 10 4 4 4 Menu Design 44 5 View Edit Menus 4 4 6 Delete Menus 44 7 Help a Representations Screen presentation of fourth level menu selection items b Operations Selects menu item c Memory Aids A menu selection description and on line help d Control Mechanisms The ENTER key activates the menu selection The ESC key retums the user to the second menu level 4 4 4 Menu Design A fourth level menu selection item that allows the user to access the MenuDate and MealRecs relations for the purpose of designing and storing personalized daily menus a Representations A multi table multi page screen presentation form that contains the following 1 A master form that is used to enter date and day to the MenuDate relation 2 One embedded form used to enter a patient s personal data and menu profile into the MenuDate relation 3 One embedded form used to enter food exchange data into the MealRecs relation Meal Planning Menu Edit Delete Help Design Menus Menus Figure 10 Nutrition Exercise Level Four 45 b Operations The prim
4. Controls access to three third level menu selection items c Memory Aids A menu selection description appears when selection is highlighted On line help selection is available d Control Mechanisms The ENTER key selects menu selection 36 Trend Analysis Figure 5 Electronic Logbook Level liiree 37 1 3 1 By Day Third level menu selection that gives access to fourth level menu selections Figure 6 14 1 3 Day Trend 1 4 2 7 Day trend 14 3 14 Day Trend 1 4 4 Help a Representations Screen presentation of third level menu selections b Operations Controls access to four fourth level menu selection items c Memory Aids A menu selection description appears when selection is highlighted On line help selection is available d Control Mechanisms The ENTER key selects menu selection 1 4 1 Three Day Trend This selection will result in a graph of the last three day s glucose readings for trend analysis When selected the logbook relation is accessed and the last three days glucose readings are selected based on the current computer internal clock date The glucose readings consist of readings entered for the breakfast lunch dinner and night blood glucose tests These are placed in an answer table A graph is then constructed displaying a title indicating the number of days for the graph in this case Glucose Logbook 3 Day Trend The Y axis displays the glucose range in mMdl This axis is automat
5. The logbook holds glucose readings insulin dosages date and time of injections The unit also allows codes to be entered to explain abnormal readings The systems reviewed both in the literature and with actual testing did not address all the needs of a diabetic The Merlin Diabetes Data Management System is available to manage and graph the data at additional cost Boehringer Mannheim 1988 The system includes a patch cord to upload the data in the Merlin unit to a personal computer and the associated software for either an EGA or CGA monitor The software allows patient records with limited background information to be maintained Various graphs and trend analysis functions are available through menu selections Types of trend analysis include graphs of glucose readings by meal day of week as well as providing standard deviation and mean values All of the graphs and charts can be displayed on the terminal or sent to a printer The advantages and disadvantages are listed in Table III With the exception of the Diva system all of the other units have limited memory available for glucose reading storage Also only the Diva system had any information on nutrition or exercise The Diva system was the most comprehensive but was the most complicated requiring three different units at a cost of over 1100 Finally none of the units had a dictionary of diabetic terms or provided the necessary nutrition information and charts required for compreh
6. Depleted 12 0 to 16 0 hrs 3 Long acting Takes effect 1 0 to 1 5 hrs Most effective 8 0 to 12 0 hrs Depleted 20 0 to 24 0 hrs Adapted from Travis 1985 w u Dietary requirements include daily caloric intake which must be strictly controlled another important factor in the control of glucose levels This requires the diabetic to eat a number of smaller meals at specified times throughout the day in order to maintain a relatively consistent glucose level in the blood stream to avoid glucose peaks and valleys In a non diabetic the body can very quickly raise or lower the glucose level in response to the demands placed on it by food intake stress illness or a number of other forces A diabetic on the other hand can not regulate the glucose levels as quickly because insulin injected requires time to be absorbed by the body Nor can the glucose level be maintained as accurately by manual means In the non diabetic insulin is produced on an as needed basis whereas in diabetics quantities of insulin are injected at specified times and it is dependent on the number of injections type of insulin diet and amount of exercise to maintain glucose levels within a specified range Good control of glucose levels in a diabetic is considered to be between 60 150 mg dl Travis 1985 The type of foods such as carbohydrates fats and proteins must be carefully monitored to keep the blood sugar levels consiste
7. HAN SAYUNIY 311N 100q307 azepdn ezi on on ers zsooms cil van han N10 NAT eeg ca ysoday 100qh0 350IN 9 S quand ev emd aa on 8 86 350008 cal HAN wud 58 5ny 91 2332 08 9 St 2 NSS aj ves samen S JUITIES 6861 a ysnbny 61 Trend Analysis By Meal Figure A4 Electronic Logbook Level Three 62 13 3 Help b Level Three Structure 1 3 1 By Day This selection allows the user to select trend analysis of a previously selected patient glucose logbook The trend will be based on a selected number of days of glucose readings The day selection leads to a fourth level sub menu consisting of Figure AS 1 4 1 3 Day Trend 1 4 2 7 Day Trend 1 4 3 14 Day Trend 144 Help c Level Four Structure 1 4 1 3 Day Trend This selection will present from the patient s logbook the last three days glucose readings in a graphic form This will allow trend analysis Figure A6 1 4 2 7 Day Trend This selection will present from the patient s logbook the last seven days glucose readings in a graphic form This will allow trend analysis 1 4 3 14 Day Trend This selection will present from the patient s logbook the last fourteen days glucose readings in a graphic form This will allow trend analysis 1 4 4 Help The Help selection provide on line help to the user 63 By Day SNE 3 Day Trend 7 Day Trend 14 Day Trend Help Figure A5 Electronic Logbook Level Four 64 Se
8. The PgUp and PgDn keys allow the user to change from one page to another The master form MenuDate enforces referential integrity by providing the following links 1 A one to many relationship from the MenuDate relation to the MealRecs relation The relations are linked on the key fields SSN and Date A one to many relationship from the Menudate relation to the Profiles relation The tables are linked on the Key field SSN 4 4 5 Edit Menus The Edit Menus selection allows selecting and editing of a patient s menu records A prompt will ask for the patient s Social Security Number and the date that 94 the menu was prepared The screen will display a multi table form exactly like the one that is used for Menu Design Use the cursor keys previously described to move to the field s that you wish to edit and enter the new values Press F2 to complete the session 4 4 6 Delete Menus This selection allows deletion of menus This is accomplished through a prompt that queries for the patient s SSN and the Date of the record s to be deleted f Level Three Structure 4 3 3 USDA Food Values This selection gives access to the USDA Home and Garden Bulletin 72 Two sub menu selections are provided at this level Figure A24 4 4 8 View USDA Bulletin 44 9 Help g Level Four Structure 4 4 8 View USDA Bulletin This function will allows the display and viewing of the entire USDA Home and Garden Bulletin 72 The screen presentation is
9. Type II diabetes may or may not be insulin dependent and can sometimes be controlled with diet and exercise Although this system is focused on insulin dependent diabetes three of the four applications could be of significant use to Type H diabetics In Type I diabetes the immune system for unknown reasons destroys the beta cells The destruction of these beta cells results in little or no insulin being produced by the pancreas Without insulin the ability to transport glucose into the cell is lost The cells in their quest for energy will use fat stores in order to obtain this needed energy As fats are converted into energy ketones are produced in the liver which build up in the blood stream This can lead to diabetic acidosis a serious condition which can result in death In a normal person the glucose level is maintained on the average within a narrow range of 60 80 milligrams decaliter mg dl by a complex combination of organs and hormones Type I diabetics must manually maintain their glucose levels with daily injections of artificially produced insulin As a result of not being able to produce insulin on an as needed basis diabetics must try to keep their glucose levels as close to normal as possible artificially In order to maintain stable glucose levels a combination of diet exercise blood monitoring and insulin injections are required Diabetes is a complex disease and the complications have far reaching effects on the
10. table with all the possible selections The user highlights the desired selection and presses the F2 key to enter the data into the form Default entries are provided to reduce the amount of information that is needed to be keyed in The user is required only to place the cursor into the field that has this capability i e a date field and the current date in entered from the computer s clock when the cursor is moved from the field The next chapter will discuss the conclusions of the entire process 47 V DISCUSSION AND CONCLUSIONS A USES OF THE DIABETES SUPPORT SYSTEM The Diabetes Support System has a number of advantages to offer both the health professionals and the diabetic The major advantage of the system is it provides a central location for the vast amount of information needed by the diabetic and the medical center in an easily usable form By centrally locating the information the system could ideally be used as a teaching aid for the new diabetic A significant amount of the information needed is provided The system could also be used in the hospital or the clinic to get the patient comfortable with the daily routine of diabetes maintenance This will build the patient s confidence more quickly and allows the physician or teaching nurse to monitor the patient s progress to determine when he is ready to be on his own The menu structure is simple and can be used with limited computer experience With use of this system the dia
11. Help k Level Three Structure 4 3 7 Food Exchange Charts This report contains food compositions for a selected Food Exchange A message will prompt you to enter the food exchange chart that you wish to print Figure A28 4 3 8 All Charts This report contains the entire Food Exchange data base It lists foods and food compositions by food exchange category 43 9 Your Daily Menu This selection prints the daily menus designed with the Menu Design function The user will be prompted for the patient s SSN Once this data is entered the menu for the current day is printed Figure A29 4 3 10 Fats This report displays the nutritive values of foods in commonly used household measures The user will be prompted for the food category to be entered Once this is done a report is generated The report contains the following data Figure A30 101 July 10 1989 Foco Descriptian FOOD EXCHANGE E ANIMAL COOrIES KAKED POTATO EEANS Red or white ETSC BREAD BREAD Liw calsrie BREADCRUMES Dry CEREAL Ceci ed CEREAL Dry Figure A28 FOOD EXCHANGE CHARTS Exchanae Charts Grouped by Food Exchange Excha Units Per Food Measure Cal PMFVOE 8 each 75 1 1 ea small 75 1 1 cup 78 i 1 each 120 geek 1 slace 7 1 en TAS 1 cup 75 1 1 cup 75 1 1 cup AS 1 Food Exchange 102 Page Pro Car Fat Ch Sod dE a 18 ze HE s 15 aS IE dE SE ME Charts o o O O O 0 Report Prepared
12. a July 11 1989 Page Total Exchange Units per Food Tot error cee cee ccess Tot Tot Food EX Measure Cals Pro mik Frt Vea B amp S OAF Chis Sud MENU PREPARED FOR Steve Albert 11 Jul 93 Meal Br ANIMAL B 1 00 each 75 o 9 COOKIES BACON o 1 00 strip 33 0 0 0 0 0 0 0 0 0 0 1 0 D o BANANA F 2 00 each 390 0 0 0 0 2 0 0 0 0 0 0 0 O 0 Meal Totals EO Woh Wok Sole Blow Hat Wate o O Meal La BEEF BRISKET P 2 00 lb 2 0 0 0 Meal Totals O 20 0 0 0 0 0 0 0 0 0 0 O o Daily Totais END Zok OO Be Hod ath o D Figure A29 103 Daily Menu August 23 1989 Grouped by Food Category Page Food Description Measure Cals Fat Sat Mono Poly Chols FOOD CATAGORY BEVERAGES BEER Light 12 00 fl oz 95 0 0 0 0 0 BEER Regular 12 00 fl oz 150 0 0 0 0 0 CLUB soda 12 00 fl oz 0 0 0 0 0 0 COFFEE Breved 6 00 fl oz Tr Tr Tr Tr Tr 0 Figure A30 Fats 104 1 Food Description 2 Household Measure 3 Fat in grams 4 Fatty Acids as a Saturated in grams b Mono unsaturated in grams c Polyunsaturated in grams 5 Cholesterol in milligrams 4 3 11 Nutrients This report is similar to the one above However Nutrients contains the following data 1 Food Description 2 Household Measure 3 Calories 4 Protein in grams 5 Carbohydrates in grams 6 Fat in grams 7 Cholesterol in milligrams 8 Sodium in milligrams 4 3 12 Vitamins This report contains 1 Food Description 105 2 Household measure 3 Calories 4 Vitamin in international un
13. at present there is no system that has incorporated all the features needed by the diabetic i e Logbook with trend analysis Nutrition information including Food Exchange 17 Table H DIABETES DATA MANAGEMENT SYSTEMS SYSTEM MANUFACTURER OPTIONS Data Manager LifeScan Logbook Glucometer M Miles Logbook Merlin Boehringer Mannheim Logbook Romeo Diva Logbook Limited Nutrition Exercise Charts and USDA Nurrition charts Exercise information and a Dictionary of relevant terms The features that are needed include 1 Electronic Logbook for tracking and analysis of glucose readings insulin dosages date and time of injections Patient Database contains back ground medical information 2 Nutrition information to include exchange charts nutrition charts and meal planning information 3 Exercise information to aid in exercise planning 4 Dictionary to provide definitions of medical and diabetic terminology 5 Help on line One of the leading diabetes management systems the Merlin system by Boehringer Mannheim was acquired and evaluated The hand held unit connects to the Accu Chek Il The Accu Chek II can be used with the glucose test strips to electronically read the glucose level This allows the glucose reading to be automatically entered when the blood test is conducted The system provides the patient with an electronic logbook of limited storage memory capability of 18 approximately 2500 glucose readings
14. between the record sub sections can be accomplished by using the F4 key as in the Electronic Logbook section The second level sub menu consists of Figure A9 2 2 1 Update Records 2 2 2 Delete Records 2 2 3 Patient Listing 224 Help a Level Two Structure 2 2 1 Update Records This selection allows the user to view update and enter new records When the user selects this menu item a query will ask for the last and first name of the patient record to select The user will then be presented with a multi record form containing the patient s background The Patient Records record is divided into three sections background information medical history and diet information The background information consists of the patient s name address telephone number last and next visit 69 Patient Records Update Records Delete Records Patient Listing Help Figure A9 Patient Records Level Two 70 Medical History section holds a summary of the patient s medical background This has valuable infonnation about the patient s diabetes and other diseases for which the individual may be under treatment It also contains critical information on medications to avoid conflicting treatments Another essential part of the medical section is the remarks section This allows the physician to add information pertinent to this specific patient adding flexibility to the entire system The last section holds information on patient s diet with impor
15. ea e a e ago e A a iaa tee regie PAS DS BAPE D Romeo agree pores rena cur E O gro OP pra A e EEE COM a porca pano teme il ina q ee Mi per AN ere a peeler pt ep A erk OCR PEA PT AREA ade AAA ARTS mre EEE NET RE EE O es 184 OMEN ETS RA tr pe mir ge FO UI PAP wal P BIB opa r e me GET ve phe Pet ee ga callen ace de paa ali po alo asda pi prvi eg Pira ten j eg ARE A E a A cera SR RS He DAC A CRE RS ner iedeen genen ART Le PPT OS Det dA dns PANA 4 ad aes p PERS vor drm ete need rf Par semer Ziya prete argent era en epe e codes pow popa re rt ee p A AOL tg A ma T ug a PER NE O UR eni apen H en 4 ALA LR ii RK o Lp den AA qe pa LEA ELS Fare pI FAB NTN MERE Hales Med w w wow pre enorme wes ind RPM A RE AL A A ey O TN O AAN DESERT TT ie Pertes pt 5 OEE DE ERD De Re ar ner Serer forme PES ep fra GO AST ze sya a eq neve AT Ag capi par eye A per AAG ee gd Tim en icn D por sd qui nen pe Er pe pr ATEN TRS IL LE gt athe Pe ee A H J UK tank ad LE suy penai een pees var anew de de E apen AETS pe we nn OLA oeren da AA pd Ar GD PR PI TAN MEDO aqp pe Der Enr ve TE reen rt did rentree EU Ww Yx TOM iP dad o on Freon qr e MIRA ve rene rt ae ra dl aci fera gt PAR NA PR PP IAS WAE VINENE ser raya VON Ue Tayka ar g AOL RN AAA 4 PO qua ern gn po YW ev de Pepe ge fiel qu Liss MAIN
16. example added great flexibility The personal programmer was used to build the menu structure and generate the basic code There were a number of problems encountered with this code The major problem involved errors developing after repeatedly recompiling the code after frequent changes This proved to be due in part to an existing problem that the Borland company has been unable to correct In summary some of the problems were due to the use of a newly released version shortly after a major revision The problems encountered however were not major and considering the size and complexity of the Paradox system were insignificant C THE DIABETES SUPPORT SYSTEM CONCLUSIONS The Diabetes Support System DSS proved to be a much larger project than was first envisioned as is typical of most systems development projects However a comprehensive application was developed in 4 months on a part time basis With the major backlogs of software awaiting development in most organizations a 4GL will allow the users to develop some systems themselves and free the programming department to address problems in other areas The Diabetes Support System as proof of concept shows that a comprehensive system can be developed in minimum time using fourth generation technology It also shows that decision support can be applied to diabetes control and maintenance enabling better treatment and comprehensive care 52 The Veterans Administration and the
17. individual and his or her life style Atherosclerosis develops at an accelerated rate in diabetes and heart disease is the leading cause of death in diabetics Microvascular diseases affect the small vessels of the blood stream causing damage to the organs such as the eyes kidneys gastrointestinal tract and circulation in the lower extremities Diabetes is the major cause of blindness and amputation in the United States today Ellenberg 1979 C TREATMENT OF DIABETES In 1948 the medical community recognized that the incidence of secondary complications might be reduced if blood glucose levels could he closely monitored and controlled Today it is possible for diabetics to monitor their glucose levels at home using fast accurate and reliable self testing procedures Individuals can then compare their glucose readings with a range of clinically determined values that are considered normal With careful monitoring a diabetic can adjust his her daily insulin dosages to a level that will keep blood glucose values within this normal range However many factors can affect the delicate balance of glucose and insulin in the blood Diet and exercise are among the most important of these regulatory factors Figure 1 Blood monitoring is a complex process which requires the management of insulin dosages insulin types and analysis of blood samples taken by the individual There are a number of regimens of blood monitoring and insulin injections ran
18. military medical systems are overtaxed and in need of automation A Diabetes Support System that can be used as a teaching aid and as a management tool will reduce much of the administrative work load on the staff This application allows for easy maintenance of patient records as well as specific trend analysis meal planning and exercise programs By having much of the data needed to manage diabetes in one location valuable time can be saved for more critical needs In high volume clinics the physician does not have the time to spend with each patient By being able to quickly access the patient s history and any personal data the physician can at least give the impression of personal involvement one sees in small clinics This will reinforce the patient s feeling that someone cares how they are doing encouraging him to stay on the strict regime D THE FUTURE Some of the reports and graphs were reviewed by endocrinologists and some enhancements were suggested This entailed the addition of statistical data such as mean and standard deviations It was also suggested that a 30 day glucose scatter graph be added to the selection These features could most likely be incorporated into the system without major changes The Diabetes Support System is at a point where a comprehensive testing phase is the next step After corrective maintenance for any errors has been finished the system should be beta tested in a clinical situation or a endocrinolog
19. six months This was based on the premise that many of the users will have limited computer experience 3 The requirement to deliver a system that would provide a useful decision support system and enhance user productivity The system had to appeal to physicians dieticians and diabetic users 4 The requirement to identify and apply advanced technology to solve a complicated project and show proof of concept 1 ROMC and Prototyping The ROMC approach is suitable for this type of project It is an iterative process that is characterized by prototyping ROMC gives a builder the flexibility to design a Decision Support System without needing to first identify all of the user s 21 decision making processes Sprague and Carlson 1982 point to other advantages that include 1 Help DSS builders and users to segment the decision problem and identify the relevant intelligence decision and choice of operations 2 Allow the builder to design a set of representations with associated operations rather than a set of operations that result in representations Prototyping through the process of iteration allows the builder to construct and deliver to the user a working model at the least expense early in the development process Together the builder and user can refine the model with each successive iteration This process promotes maximum user participation throughout the development process and provides maximum flexibility for incor
20. taken to correct them Early detection and analysis of trends promotes tighter control This allows smaller adjustments in insulin diet and exercise to be made Maintaining tight control reduces visits to the doctor and may prevent hospitalization In addition to promoting good health most physicians feel that tight control of glucose levels will lead to fewer complications arising later in life This will reduce the strain on the medical community and improve the quality of life for diabetics At the present time both diabetics and medical personnel who are not familiar with diabetes treatment must manually study logbooks of glucose readings diet plans food exchange charts and exercise tables in an effort to sustain their own or their patient s glucose maintenance programs This is time consuming and it is frequently difficult to conduct trend analysis and exception reporting with the amount of diverse information needed If these functions could be provided quickly and easily they could prove extremely useful in identifying trends and in maintaining control of blood sugar levels With this system small hospitals clinics and individuals could identify trends sooner and make needed changes Diabetics and health care professionals must make numerous important decisions daily in the control and maintenance of diabetes How much and what combination of insulin is required How many calories to consume Menus must be planned with the proper bala
21. the scope of the project was discussed with the director of software development for Boehringer Mannheim Merlin Diabetes Monitoring System and Dr David Rodbard at the National Institute of Health Dr Rodbard and his colleagues were among the early pioneers in the development of software for monitoring diabetes Both gentlemen stated that this project was probably not possible in terms of budget personnel and development time However it should be noted that Boehringer Mannheim and Dr Rodbard used third generation programming languages to develop their respective systems compiled Basic and Pascal respectively Based on these interviews and the project s constraints it was decided that the only feasible way to accomplish the task was to identify and utilize a state of the art fourth generation software package The software features considered essential to development were 1 A microcomputer based product 2 A DBMS preferably relational 3 An application generator 25 4 A form generator 5 A report generator 6 A programming language 7 Graphics capability 1 PARADOX 3 0 After a thorough review of leading edge software products based on software demonstrations and review of the major industry trade journals and periodicals Borland s Paradox 3 0 was selected This product was a significant update of an earlier version Paradox 2 0 In addition to meeting the selection criteria Paradox 3 0 categorically out performed all t
22. user with a graph of the last seven days breakfast glucose readings for trend analysis 1 4 3 14 Day Breakfast This selection will present the user with a graph of the last fourteen days breakfast glucose readings for trend analysis 1 4 4 Help The Help selection provide on line help to the user Other meal selections will be added for lunch dinner and night when the application is readied for beta testing 4 Nutrition Exercise The Nutrition Exercise selection provides access to dietary planning exercise and nutritional information By selecting a variety of decision support functions can be performed to include 84 1 Viewing editing data entry and printing food exchange charts 2 Designing editing deleting and printing personal daily menu plans 3 Viewing editing and printing USDA food composition values 4 Viewing editing and printing an exercise activity chart 5 Viewing on line help screens that are available at each menu level This section outlines the Nutrition Exercise menu structure Selecting Nutrition Exercise causes the screen to display two second level menu selections and three menu functions Figure Al8 4 2 1 Nutrition 4 2 2 Exercise 4 2 3 Reports 4 2 4 Help on line help available at each menu level 4 2 5 Leave retums to the Main Menu a Level Two Structure 4 2 1 Nutrition The Nutrition selection provides access to the food exchange charts meal planning functions and USDA Home and Garden B
23. 4 Ca Ces 105 logs Boie ajo Dailv Calorie Intake 1582 Choiesterol LDL 35 HDL 137 Low sodius Y N Y Low Fat Y N Y Keaarhs Figure A10 2 Huaulin REG Diseases 2 3 Medication Cairo ms oo es em Remarks Patient Record 72 After the name has been entered a master patient data form will appear This form will consist of three sections a Patient data Medical History and a Diet Information The Patient Records section contains the patient s name last name and first name Next is the Social Security Number this is the key field and is a unique number for each patient This is followed by the patient s age and address The Zip Code can be entered as a 5 digit number or as the Zip 4 number The Last Visit and Next Visit are dates used for tracking quarterly clinic visits The Last Updated field allows the physician to determine how recent the information is for each patient The birthday field is an information field The height and weight fields are entered in inches and pounds and automatically convert these to metric values and displays both U S and metric values The Medical History section comprises information on the medical background of the patient The first entry is Age of Onset to indicate how long the patient has had diabetes This information is important in order to determine the types of medical problems that might exist or develop The range and hypoglycemic provide information the normal glucose rang
24. A Q e PETER fa are sea res 5 as Ie A A a A Er ee ont 2 Fester n ee rG a o CE gn wate TE en 3 os Nesta mer gia ty AE Ss Bis ad Sergi LAS CU se o Doado uel ad a pp cect eng ato rg reed ie een rk zes Ex prevare chart C E rS Ree A PONE PU reen demo DL ee p PPT E peep papo e P me peg le mar SOTELO er lA AE a e Se Pere AG o A REO none gu im A TO Pe rt Pet tp ii s Ed A Eer lees Set aves vee W a 24 CRC TNT ET eve Re pee Te event pe CODE TN gegen n ane h page 4 arar TE Hess po PRE reuse tte enr rs ami any En pu Er orig n pa A SAT terre Are ROT rme Le war Sh 9 ugut TE UE D pa e i F wiles at al rte a gran Asen or nae TE en afp aera hes dienes man parir o en sa ct SE apie gue pira q P spp regue ng fas LE a AS pirata Seen en rear OL Ap LIA gt eg PATES pe erf Vi ii efa a ei A de a Del 71 el arr westen er arde Da o ad ee Pi tm E e ESSE Er Tt td a AR A at A A A A AN qua w pap pag quan ra are ee im mi epee DONS LEE A er aa verevenen pares een ae no jp PRES pe pompa et a werner apego vi o PE rz EE Eee a dl ae ee PACA pte Ep pe generen pn af f YN SOL qa PTE gend ne pa pr AGE ve O ew P pepa y er PL ere oa pro uam Magoo nero quais de po ab oor verd PARMI 1 ue y EEr AR PA E en re ae 1222255 a ag Apr Rd UA
25. AISLADA este A ewer ve pire prete os a reduto ef e qr iris E RA DNA pa uywa yawa A UA a aW ra a dera Du PEA fu Eu even aren TU varen an en A OA A A ta OT La a rca net A ve as es an eat oe UPSSSC dai me Ei a Dep Ay pager er AA EA ds CPE ed He erg ea vpn pkey de EE a dend were DO En CRT Te rep ren ener neee En pe Pia zage Pan rama ser ast overveen ben at geenen ron i ART TT ae te ee ea upr mepa yr ete gee Z a CAR ME EE GR EEN Pan pd pa MENTION ESS Aiton W gongo Pacha fin rh hag someren reg aeron foe LASER DE GES DS wa ee ae Fe nyera D RS q EM Le pte y ea penn aw EYE E FOE runa VD OT ATTY JUEGA TOTANA ANA AOSTA Y ot het re A Oet e del End d a sane MR lt ad rt ro Loner TNT Sor rope HONTE EEEN pra mare ANA TRAIN av avr o ever tea va a en Sr even van A rp yaya RTS wr AUS rye Lae Pen Ur we receio or Se ra pio IN Aera anarien tarn enb eat Peen be ere Ges japans ggn ones ace Re PRET or pate ee Ga Poe ey y gt gt n CORRE aia e RA e d de ce ss w man O W ys de y wine a SON partner PAR td ears ver CE 1 ee ore Dane SV et nee oa EE E dp eus rye ERA wes Ae peca res one Vo rb sad py a E FUM E LA w wao 1255 Esta n nor Raia tor pins oi greta areal gt CCE vn qu oem ON DONS eons arbre MES ro 1 Hae a zon 156 Vere lek q UN OU re nr ris NAVAL POSTGRADUATE SCHOOL Monterey California A P
26. EE SK NEN EWA e JE SSS Three Day Trend Analysis Figure A6 65 d Level Three Structure 1 3 2 By Meal This selection allows the user to select trend analysis of a previously selected patient glucose logbook The trend will be based on a selected meal for a number of days of glucose readings The meal selection leads to a fourth level sub menu consisting of Figure A7 1 4 1 3 Day Breakfast 14 2 7 Day Breakfast 1 4 3 14 Day Breakfast 1 4 4 Help e Level Four Structure 1 4 1 3 Day Breakfast Figure A8 This selection will present the user with a graph of the last three days breakfast glucose readings for trend analysis 1 4 2 7 Day Breakfast This selection will present the user with a graph of the last seven days breakfast glucose readings for trend analysis 1 4 3 14 Day Breakfast This selection will present the user with a graph of the last fourteen days breakfast glucose readings for trend analysis 1 4 4 Help The Help selection provide on line help to the user 66 By Meal 3 Day 7 Day 14 Day Help Breakfast Breakfast Breakfast Figure A7 Electronic Logbook Level Four 67 Glurose Logbook 3 Bay Trend Figure A8 Three Day Breakfast 68 Other meal selections will be added for lunch dinner and night when the application is readied for beta testing 2 Patient Records Menu Structure The Patient Records selection allows the user to view update add or delete patient records Moving
27. EN DI a x ta AAA a ee A mae ey SR x A 3 A g meae oro ee a krm P HAD pa ea N CR 5 an En ai e TG A wawas Pv 8g A Den ns z n F AAA waqan Fe er wawaqa q YET a lt rs heel Rod a i a prm er sr s rr Spa a wend 1 ae x ix Nuit A AL AS Rd eh eu ar de Lis dada PU O To RA ETES e ee enr A org mien en ete EE DE w lt SIPS ETE w w OLE been v CORRE A o ern ae he MO EEE Le LIN De gt ww w ar deeman a iy a Ay Aur 0 m e Weme u y VARO OA A e a oa Leh rrd A Guat eet IR RRA ara e a es o A qdo Tem a Te fade te sera OC x maA dd A eE ely op derven Gt er je 1 S 4 1 sr spe ve Meg PA LE ir do te s ae a gt pe aeg vree NE ee cita e amet MOD ME berde ENT s Z ERC na E Nea hg o ye eh a eu vn sia es gt at COR ONE e z DUI Ns hw gt ht we wrr id se r DDR S a WESELE IR anve aa ya me ee i TA E je a i w Ba rh a ar Q W w s lt waya STARS th he id dap OT RTE CENTS Y bre tay Le viens eee e nil LE FED SMe ag re tisa PE SE PEN E ede H E ie me re I ON Tey ara EN VOE Pe GPU PT e O mn CE pn Ma EE PS A A A PLD EA do y rune PPP Pr ANN MAS VIe lt we lt a oe nn ue rev ur NEN w de y TE a paard nije DORE Mo vom PE RS SR E o temen armere OP ee Apio Aaike do o Pad 2 e poima Eur me D ae MOE Ne COST M SRE t i FP PEA RA RO ERGENS A Sew a
28. RATS SET SO PE AU eae ade ata ge dee Ste oe wr er ven a D e be Ron Sa EU CR k ES ICE PET ICT EME a Ee DA Bd w w LR RL TL EE rs ci A do CA findo tdo URL ae Je io dd merten Ay y rene ek arne Apr en atin e Sau i SE OG HEP a tign gekreund ns PURI RO oer rd po a Why ia ralo PR ES a Tra arenas sya NET RE v SE an e UGE AGR a rt IT sz yura un UA tn ne Why usa WA Q Cleo kiy w Er EO a Em eee M 6 DETTE ER COCO OCEAN pia rated a PRENSA Paty IEA breve e waqu a oaa Er a EP eng ra 0 ASS ad pad di er A EE A OT EEE AS Aka AE DE ive nd PE eg siete UV WET ores On NES ee AA STI ENTER RTE CR EE RENE Ne nr wr dn suf we RA me sur wie z Ter pos ques PAP TE at eh GPU re P is qe es ama a wis oa pn tra tk e Te Gain NEN pans Dee uia E Sarre ut Eg DIEWE DD Gov ny ete there een pnt nk Oe err dle Pop Ku a A A ED dn Te A y A eT S WER n WE vent neg Pre zeten es rare ppt AA A ES eo vi o Aa fa A I nara ee vue e EA VIVIDA r Sd ELD LEDE aen SA A ae vie var re mpeni s ARE HPs EE L ty on ok DUR EV en te ea v eper ti v AAA Ma gio Rad G f s poe dd eme sore
29. S 101 1049359104 33910 384 0 3391 entpos no e2 BAG cagequ sojey jieg by q1 0511 iyb1an 0 ul B 29 ubl H u01 P0JOJU 3910 y abeg SPI009Y JUSTE 54Jeway N r EEEN 994 UE nent HAN ut nunH utqnsu d b8bt Jaquada 3 e0 TA 319 QH SNotaauy 6861 1 senagas aj 9 6 DIY QH 1581 Or ojaq JtwarAjbadAy 19 1P 021 0 08 zabuey asoonig jeap 91 l su0 jo aby 6861 EZ Aew spajepdn 1521 JOYStH eItpay u011ewjJOjU punasbyzeg 4u 11e4 ZIV 240311 G5 18 1 Aepyys1g L9Se Z1 8Br cauOUd 68 10 p JUSTA JAN 68 18 1151A JSP 000S Sh z 1 du 2 cajeas UMD JMO 24319 7S APO FZI ssasppy saby 4 IN ajdees 3a eN 1541 Beg 28PN 15e 08 9 Gh 2 NSS eje quatjeg 4861 ez ysnbny 77 GGGS 21 L96y 21 BOM auDyd 68 90 6 68 18 68 98 9 68 18 1 bg 2 VISTA PKAN JISTA 158 8727S I abeg duist JUSTE UMOJ J u19uU UNO 3n04 ce 4119 aby butys17 yuaryeg Y 8 IW va dues PJeq a dees ejef AMEN 35414 AREN 3587 6801 ez ysnbny CIV and 68L9 Gr L21 BBLI Gr LI NSS 78 Trend Analysis A Figure Al4 Reports Level Three 79 The By Day selection consists of a menu consisting of Figure 15 3 4 1 3 Day Trend 3 4 2 7 Day Trend 3 4 3 14 Day Trend 3 4 4 Help c Level Four Structure 3 4 1 3 Day Trend This selection will print a report of the patient s logbook th
30. TE OF REPORT year month day 15 PAGE COUNT laster s Thesis From To September 1989 115 b SUPPLEMENTARY NOTATION he views expressed in this thesis are those of the author and do not reflect the official policy or position of the Department of Defense or the U S overnment 7 COSATICODES 18 SUBJECT TERMS continue on reverse If necessary and identify by block number FIELD SUBGROUP Diabetes Decision Support System e 0 HP PA 9 ABSTRACT continue on reverse if necessary and identify by block number Diabetes is a serious disease that affects many peuple The military medical system is one of the largest medical systems in the world and eats a significant number of dependent diabetics As with most sections of the military the medical community ts understaffed This results in ost facilities lacking adequate medical care for these patients The key Lo the treatment of diabetes is control of blood glucose levels and the ntributing factors such as food and exercise By controlling these factors large fluctuations in the glucose levels can be minimized A decision pport system that enables both the medical personnel and the patient to manage these factors could vastly improve treatment and mitigate the de effects of diabetes This paper will address how such an approach can be applied to diabetes resulting in better medical care and decrease the emand on a stressed medical system O DISTRIBUTION AVAILABILITY OF ABSTRACT K UNCLASSHFIEDI
31. UNLIMITED CI same ASREPORT OTIC USERS Unclassified rufessor Moshe Zviran 4081646 2489 54ZV D FORM 1473 84 MAR 83 APR edition may be used until exhausted SECURITY CLASSIFICATION OF THIS PAGE All other editions are obsolete UNCLASSIFIED Approved for public release distribution is unlimited A PERSONAL COMPUTER BASED DSS FOR DIABETES CONTROL AND MONITORING by Richard A Blow Lieutenant Commander U S N R M S CORPUS CHRISTI STATE UNIVERSITY 1984 AND Steven P Albert Lieutenant Commander U S N B S UNIVERSITY OF TENNESSEE 1977 Submitted in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN INFORMATION SYSTEMS from the NAVAL POSTGRADUATE SCHOOL 1989 J Y ABSTRACT Diabetes is a serious disease that affects many people The military medical system is one of the largest medical systems in the world and treats a significant number of dependent diabetics As with most sections of the military the medical community is understaffed This results in most facilities lacking adequate medical care for these patients The key to the treatment of diabetes is control of blood glucose levels and the contributing factors such as food and exercise By controlling these factors large fluctuations in the glucose levels can be minimized A decision support system that enables both the medical personnel and the patient to manage these factors could vastly improve treatment and mitigate
32. York N Y 1988 Sprague and Carlson Building Effective Decision Support Systems Prentice Hall Inc Englewood Cliffs New Jersey 1982 Travis Luther B An Instructional Aid on Insulin Dependent Diabetes Mellitus Stafford Lowdon Fort Worth Texas 1985 Turban E Decision Support and Expert Systems MacMilan Publishing Co NY NY 1988 United States Department of Agriculture Handbook Number 451 Nutritive Value of Foods in Common Units Superintendent of Documents U S Printing Office Washington D C 1988 107 United States Department of Agriculture Home and Garden Bulletin Number 72 Nutritive Values of Foods Superintendent of Documents U S Government Printing Office Washington D C 1981 108 INITIAL DISTRIBUTION LIST Defense Technical Information Center Cameron Station Alexandria Virginia 22304 6145 Library Code 0142 Naval Postgraduate School Monterey California 93943 5002 Professor Moshe Zviran Code 54Zv Naval Postgraduate School Monterey California 93943 5002 Professor Tarek Abdel Hamid Code 54Ah Naval Postgraduate school Monterey California 93943 5002 Richard A Blow 40190 San Carlos Place Fremont CA 94539 Steven P Albert 805 2nd Street Pacific Grove California 93950 109 Tne s s 55091 Biow osi A personal conputer based DSS foz diabetes control aad monicoring pu y D TIT L gt 200874 ANT DO A VI 002
33. ablish a baseline for developing a treatment regimen The primary goal of an effective regimen is to monitor and control SITUATIONS Decisions for Diabetics Figure 2 10 the level of glucose in the blood stream The term control in this context refers to the degree that a diabetic manages to keep his her blood glucose level within a specified range The acceptable range is generally considered to be 60 to 180 mg dl Travis 1985 however diabetics are encouraged to strive for the good control of 80 to 120 mg dl This usually requires a strict regimen and close monitoring on behalf of the individual The success of a treatment regimen is strongly influenced by the following considerations 1 A positive and cooperative attitude toward treatment 2 A thorough education on the fundamentals of diabetes control 3 The design and implementation of a treatment program that is stringent enough to maintain control and at the same time flexible enough to provide the diabetic with the means to live as normal a life as is possible The complexity of diabetes and wide nature of knowledge needed to maintain and control the disease is an area that could vastly benefit from an automated decision support system and is the focus of this system 11 IL SYSTEM ANALYSIS A THE NEED FOR INFORMATION The previous sections have shown that diabetes is a complicated disease and requires a wide variety of knowledge to properly control and m
34. adily accessible list of diabetic and medical terms plus definitions for the user to answer frequently asked questions 55 AD T dIeH A1puo 21q SUOF2816S NUON UJON IV embjy OSIDICXI UOT TIJN sliodey piooSeq luetiod 100807 O3IQ0 112901g 56 f Help At each menu level there is a Help menu to provide on line help to the user g Leave The leave selection is used to quit the DSS program and retum to the DOS level B CONTROL MECHANISMS 1 Function Keys This section provides a description of the various keys used to control the movement of the cursor and initiate complete various functions throughout the application l 2 ENTER used to activate menu selections or functions ESC returns you to the previous menu with one exception When performing an edit or data entry function the ESC key can be used to cancel those functions TAB used to move the cursor horizontally from field to field The Right Left Arrow keys same as the Tab key The Up Dn Arrow keys used to move the cursor up or down F1 F2 used to activate a table lookup function This is accomplished by placing the cursor on the designated field and pressing the Fl key This will place the lookup table on the screen Move the cursor to the record that contains the data that you wish to copy Then Press the F2 key this will complete the function F2 only used to complete editing or data entry function This will return you t
35. aintain The volume and diversity of the information can quickly overwhelm the new diabetic One of the biggest problems is finding the information that can answer a specific question With the new diabetic a vast amount of information is provided in a short period of time when the patient is first diagnosed At this time the diabetic is under great stress and is undergoing various stages of fear and denial This leaves the patient s learning ability and retention severely limited Also the sheer volume of information needed overwhelms the diabetic and further increases anxiety The diabetic feels that he will never leam what is needed or he might make a mistake that could cause serious complications or even death The first few weeks is also a time when the physician dietician and nursing staff are inundated with frequent phone calls for basic information Travis 1985 Even after the diabetic feels comfortable with the day to day maintenance of his disease the individual must cope with a myriad of decisions daily Although diet exercise and insulin are interrelated the decisions can be grouped around these themes The following are only a few of the decisions that are required 1 Insulin regimen and blood glucose levels a Blood glucose level must be checked regularly The resultant readings will affect insulin dosage insulin types and frequency of testing If the readings 12 indicate the glucose levels are within normal ranges normal i
36. ary function of this module is data entry This is accomplished through the multi table form Data entry operations include 1 A table lookup function used to enter data from the Profile relation into the MenuDate relation This is activated when the cursor is placed on the SSN Social Security Number field 2 A table lookup function used to enter data from the Foodex relation into the MealRecs relation This is activated when the cursor is placed on the Food field 3 A table lookup function used to select and enter the value for the Day field This copies the selected day value from the auxiliary Days relation into the MenuDate Day field 4 A table lookup function used to select and enter the value for the Meal field This copies the selected Meal value from the Codes relation into the MealRecs Meal field 5 Keyboard entry to the Date and Units fields c Memory Aids screen message located at the top of the form prompts the user to select the F2 key to complete the data entry process ESC to cancel and CTRL U to undo last change It also includes specific instructions for entering data d Control Mechanisms The master form has the following embedded control mechanisms 1 The F2 key completes the data entry process and retums the user to the main menu 2 The F3 and F4 keys allow the user to move the cursor from one embedded form to another Up and Down respectively This allows the user to activate the data entr
37. ation The primary function of this module is data entry This is accomplished through the multi table multi page form Data entry operations include 1 A table lookup function used to enter data from the Profile relation into the MenuDate relation This is activated when the cursor is placed on the SSN field and F1 is pressed A Profile relation will be displayed on the screen Move the cursor to the SSN of the patient whose menu is being designed and press F2 This will perform the table lookup function and enter all of the appropriate data from the Profile relation into the embedded Profile 91 Meal Planning Menu Edit Delete Help Design Menus Menus Figure A22 Nutrition Exercise Level Four 92 F2 Data entry cospleted Esc Cancel data entry Ctrl U Undo last change PqUp Padn selects page For Table Lookup Fl activates F2 cospletes data entry Instructions Move cursor to SSN Press Fl Select record from lookup table ang press F2 Move to Date and enter or just press the spacebar for todays date Move to Day a perfora table lookup Press PgDn to enter toods MENU PLANNING INFORMATION SSN 129 46 1802 Menu Profile for Steve Albert Breakfast 28 1 5F 1B Morning Snack IF Lunch 1P 18 10 Afternoon Snack 1B 1V J Dinner 18 1M 1V 2P Evening Snack 1F Optional iB In 1 Tals 1750 Chols 600 TSoa 200 x Menu preparation date Monday 21 Jul 89 Fi
38. be reviewed and suggestions or alterations can be made easily The Dictionary section although of little use to the physician is of great use to the patient in answering questions and clarifying terminology used by the physician At this time no other diabetes data management system is available that has all the features of this system Another major advantage is the flexibility of the system Most systems on the market are very structured and allow only certain information to be input With the use of the remarks sections the physician dietician or the patient has an area where specific comments and amplifying information can be stored This eliminates the need for the patient to remember codes to explain various glucose readings The physician also has more information available about the patient s medical history such as other diseases and types of medication the patient is taking to avoid conflicting treatments 49 If the system is run under Paradox the query by example feature is available for ad hoc queries This will allow for almost unlimited flexibility in information access and could be used in clinical research This may be further enhanced when Structured Query Language SQL is added by the end of the year The system also has the capability of being used as two stand alone applications The system can be used as a total Diabetes Support System with all its features or the Nutrition Exercise section can be used separately This w
39. betic can start taking charge of his life sooner The Patient Data section can be used by the physician to provide background information on the patient to refresh his memory prior to seeing the patient This would be beneficial in large or high volume clinics to improve the personal touch It will provide essential information on medical history and diet needed for each visit The Electronic Logbook can be used by bath the physician and patient to monitor the patient s progress with glucose monitoring and insulin manipulation By having printouts and graphs of the three months of glucose readings available the physician 48 can easily identify trends without the need to leaf through pages of a standard hand written logbook The patient is able to use these features to monitor daily trends and make needed adjustments to maintain control The key to diabetes is control of the blood sugars and being able to identify the need for changes enables control to be maintained Meal plans and exercise plans can be reviewed if control has not been good The Nutrition section can also be used by the dietician and the patient for meal planning and discussions about food exchanges and caloric intake With this system the patient has the ability to plan and printout daily menus to aid in calorie intake and nutrition requirements This will allow a better exchange of information for an essential element in diabetes control Menus planned by the patient can
40. ction is reached The second number 3 indicates the selection is at the third menu level and the third 1 number refers to the first menu item Update Patient on that level 54 Main Menu The Main Menu includes 7 selections consisting of Figure Al a Electronic Logbook The Electronic Logbook maintains a listing of glucose readings and insulin dosages by calendar date This allows easy trend analysis so insulin dosages exercise and food intake be altered to maintain blood glucose levels within desired levels b Patient Records The Patient Records selection contains a database containing the patient s background information to include address medical history and diet c Reports The Report section provides copies of Patient Records Patient Glucose Logbook a Patient Listing report and Trend Analysis graphs to the printer d Nutrition Exercise This selection provides two sub sections one for food related information and the other for exercise The nutrition section contains a comprehensive database of foods and diabetic food exchanges It allows the user to build weekly menus determine nutritional values of foods and caloric intake to better enable the user to monitor food intake The exercise selection allows the user to access a database with exercise information on caloric expenditure for various exercises This allows the diabetic to use exercise to aid in maintaining glucose levels e Dictionary The dictionary provides a re
41. d Exchange View Edit DataEntry Exchange Charts Figure A20 Nutrition Exercise Level Four 89 F2 Data entry completed Esc Cancel data entry Ctri U Undo last change FOOD EXCHANGE CHART Food Ex Units Meas Cals P Ex M E B Ex F Ex V Ex Q Ex Chol Sod CANTALOUPE F ood selon 45 0 0 9 0 9 0 1 0 9 0 9 0 0 0 CARROTS aS cup 25 0 0 9 0 0 0 0 0 0 0 0 0 0 0 CASHEWS Whole O 6 each 45 0 0 0 0 0 0 0 0 0 0 1 0 0 0 CATSUP 2 tsp 20 0 0 9 0 0 0 0 0 0 0 0 0 0 0 CAULIFLOWER v 5 cup 25 0 0 9 0 0 0 9 0 0 0 9 0 0 0 CELERY STALKS V o cup 25 0 0 9 0 9 0 9 0 9 0 9 0 0 0 Figure A21 View Edit Exchange Charts 90 d Level Three Structure 4 3 2 Meal Planning This selection allows the user to plan edit or delete daily menus through a sub menu that contains Figure A22 4 4 4 Menu Design 4 4 5 Edit Menus 4 4 6 Delete Menus 4 4 7 Help e Level Four Structure 4 4 4 Menu Design Figure A23 This selection allows the user to design personal daily menus Selecting this item provides access to the MenuDate Profiles and MealRecs A multi table screen form that contains the following 1 A master form that is used to enter date and day to the MenuDate relation 2 One embedded form used to enter a patient s personal data and menu profile into the MenuDate relation 3 One embedded form used to enter food exchange data into the MealRecs rel
42. e srs O CCC 3 NORTON LIN SO a apta Lo Pt e POR EER ERN En ne Naira RES aasan a Pv APS a ie a sates rh RES bats 22 pai f ET er Ea LA ean TPE CLP EME t erare rir panier E AC oh hs apra 0 Bon A W Ae A w Ra er ARE MAN a na Apr Longen koe Arte ns w mr vs AREA VERLO PRADO Y thy pa SSD at AG Pr ee Pag ard a aay ks rt vas danser me pirar wawan sea EE a MALI tre se RN pha engana rae TROBAN namis ea Res es LUS mu rey PA apo Modos Sa ee Mae sd el LRG ITEL ALAS ban r AAI TA ho PAL CRE N o LAB zand DOCS DS a Ye A TRAD on du E DCR EN VAS vue shattnaty elas Sms i Diane do Dodo rit ra an wean pee a Roms e Oe a Pengo pan mc se An VE Sets 2 KK Aer dns ene CORDES PDT Er El HUE eve te MAA La Aa Raha tu am rp NB AAR hj ESS ancl adm hi SUR Ever leek a Nad REED OS SHARE saree ane tarado Santar lO anne Man ganda ananas ent es ATOM PITA CN rare RASA Ra ren reco at ESPE PE De RD para pr am ATO CAN RAE A hs mere A Raja qua wa INEA b w UD VUE TOUT PARC GC PONS PAD ng ui oa rie VOC CORRE CT OS Fama dom C Ti ori A dota PEAR A Rg a ook JR SRE ARR nu te EA a DESA mA r E dd aen Aponta do veld Lansen ant tend CNP o As kr ra Cent AIT DREAM CRETE
43. e discussed in general terms with the understanding that the patient will set up a personal program diabetic normally will visit the physician and dietician once every three months for a progress review The physician conducts a test of Hemoglobin Alc at this time This test will give an indication of the overall blood glucose levels for the preceding three months On the basis of patient progress review the physician and dietician may make recommendations and modifications to the treatment reinforcing certain ideas The bottom line is the diabetic must assume responsibility for daily monitoring and control of his disease using instructions and materials provided by the physician and dietician A system that centralizes the needs of both the patient and the physician could improve the effectiveness of the efforts of each By organizing and centralizing the diverse information requirements both the patient and the physician can work together more effectively A dictionary is important for communications physicians frequently use medical terms to specify exactly certain ideas and conditions The patient may or may not understand these terms or forget 15 the specifics By having an electronic dictionary available more accurate information can be exchanged between the physician and the patient It also gives a reference source for the patient to questions that might go unanswered or forgotten at the quarterly reviews An electronic logbo
44. e and when to expect hypoglycemic reactions The last two hemoglobin Alc readings are provided to remind the physician the amount of control over the last 6 months The types of insulin used is provided in case an insulin reaction occurs Medical information about three most significant diseases and medications are provided to enable the physician to better determine which medications are appropriate A remarks section is provided for the physician to add any special comments to the patient s medical information The diet section contains a summary of the patient s diet regimen The daily caloric intake is provided along with whether the patient is on a fat or sodium restrictive diet The patient s cholesterol is broken into both high and low density cholesterol so the physician can monitor it A remarks section is added for amplifying information 2 2 2 Delete Records Delete Patient allows the user to delete a patient s records form the database The user is queried for the patient s last and first name to select the patient s record for deletion This selection must be used with caution because the records are permanently lost and can not be recovered 2 2 3 Patient Listing Patient Listing provides a listing of all patients in the database It contains the patient s names social security number age date of last visit and date of next visit 2 2 4 Help Help provides on line help to the user 3 Reports The Reports section provides a m
45. e last three days glucose readings in a graphic form This will allow trend analysis Figure Al6 3 4 2 7 Day Trend This selection will print a report of the patient s logbook the last seven days glucose readings in a graphic form This will allow trend analysis 3 4 3 14 Day Trend This selection will print a report of the patient s logbook the last fourteen days glucose readings in a graphic form This will allow trend analysis 3 4 4 Help The Help selection provides on line help to the user 3 3 2 By Meal Figure A17 This selection will allow the user to select trend analysis of a previously selected patient glucose logbook The trend will be based on a selected meal for a number of days of glucose readings The meal selection leads to a fourth level sub menu consisting of 80 By Day 3 Day Trend 7 Day Trend 14 Day Trend Help Figure A15 Reports Level Four 81 q d e XX eee OOF SS SS SS SS gy ER Sean ANS XX RERE OOS III Three Day Trend Analysis Figure A16 82 By Meal 3 Day 7 Day 14 Day Help Breakfast Breakfast Breakfast Figure A17 Reports Level Four 83 14 1 3 Day Breakfast 14 2 7 Day Breakfast 1 4 3 14 Day Breakfast 1 4 4 Help d Level Four Structure 1 4 1 3 Day Breakfast This selection will present the user with a graph of the last three days breakfast glucose readings for trend analysis 1 4 2 7 Day Breakfast This selection will present the
46. eans of obtaining a printed copy of the patient records and the glucose logbook It consists of a second level sub menu containing Figure All 3 2 1 Patient Records 3 2 2 Patient Listing 3 2 3 Patient Logbook 3 2 4 Trend Analysis 74 Reports Patient Patient Patient Trend Help Records Listing Logbook Analysis Mipure Atl Reports Level Two v5 3 2 5 Help a Level Two Structure 3 2 1 Patient Records The user will be prompted for the patient s last and first name to select the proper record A printout of the patient record will be sent to the printer It will consist of the information described in the Patient Records section Figure A12 3 2 2 Patient Listing This will provide a listing of all the patients in the database It consists of the patient s Social Security Number name age last visit and next clinic visit Figure Al3 3 2 3 Patient Logbook The user will be queried for the patient s last and first name to select the proper records The patient s glucose logbook will be sent to the printer 3 2 4 Trend Analysis The user is prompted for the patient s name to select the correct patient glucose logbook This selection leads to a sub menu containing the selections by day and by meal These in tum lead to sub menus in order to print the various trend graphs b Level Three Structure Trend Analysis has a level three menu consisting of Figure 14 3 3 1 By Day 3 3 2 By Meal 3 3 4 Help 76 5yJeway EST SION
47. ensive diet planning and control Additionally none of the systems allowed for ad hoc query of the database A more comprehensive system was needed to provide the diabetic with the necessary tools for comprehensive control and management Table III MERLIN SYSTEM EVALUATION Advantages Automatic Glucose Data Entry into Unit Memory Excellent Trend Analysis Disadvantages Can Not Enter Data Into Computer Manually Hand Held Unit Has Limited Memory Separate Purchase of Merlin and PC Software Cost No Nutrition or Exercise Information Replacement Battery and Patch Cord Difficult to obtain Need to Remember Exception Codes Lack of Flexibility 20 HI DEVELOPMENT TOOLS A METHODOLOGY A review of the systems development literature and the nature of this problem semi structured decisions indicated that a Decision support System DSS approach was best suited to the task at hand Furthermore it was concluded that the best design approach was to develop the Decision Support System DSS utilizing the ROMC Representations Operations Memory Aids and Control Mechanisms technique described by Sprague and Carlson 1982 coupled with prototyping This decision was based on the users requirements integrated decision support or specific decisions and the project s constraints The major constraints include 1 Limited programming expertise of the builders 2 The requirement to provide a user friendly working prototype within
48. ersonal Computer Based DSS For Diabetes Control and Monitoring by Richard A Blow and i Steven P Albert September 1989 Thesis Advisor Professor Moshe Zviran Approved for public release distribution is unlimited 1245589 NCLASSIED lt A mm ICURITY CLASSIFICATION OF THIS PAGE REPORT DOCUMENTATION PAGE A REPORT SECURITY CLASSIFICATION 1b RESTRICTIVE MARKINGS E ee y SECURITY CLASSIFICATION AUTHORITY 3 DISTRIBUTION AVAILABILITY OF REPORT Approved for public release distribution is unlimited gt DECLASSIFICATION DOWNGRADING SCHEDULE PERFORMING ORGANIZATION REPORT NUMBER S 5 MONITORING ORGANIZATION REPORT NUMBER S 6b OFFICE SYMBOL H applicable 7a NAME OF MONITORING ORGANIZATION Naval Postgraduate School NAME OF PERFORMING ORGANIZATION aval Postgraduate School 52 c ADDRESS City State and ZIP Code fonterey CA 93943 5000 7b ADDRESS City State and ZIP Code Monterey CA 93943 5000 a NAME OF FUNDING SPONSORING RGANIZATION 8b OFFICE SYMBOL H applicable 9 PROCURE MENT INSTRUMENT IDENTIFICATION NUMBER c ADDRESS City State and ZIP Code 10 SOURCE OF FUNDING NUMBERS Program Element No Task No Work Unit Accession Number 1 TITLE Include Security Classification PERSONAL COMPUTER BASED DSS FOR DIABETES CONTROL AND MONITORING 2 PERSONAL AUTHOR S Blow Richard A and Albert Steven P Ja TYPE OF REPORT 13b TIME COVERED 14 DA
49. ging from loose control of 1 to 2 blood samples per day and 1 injection to a tight control of 4 or more samples and two or more injections a day One of the frequently used schedules consists of 2 injections and 3 to 4 blood samples per day In this routine the individual takes a small sample of blood from his finger and uses a glucose reactive chemical test strip to determine the amount of glucose present in the blood stream This information is used to determine insulin dosages dietary intake and exercise requirements These complex factors are only a few of the aspects of diabetes control There are three basic insulin categories rapid acting intermediate acting and long acting Each category is based on the effective activity time A normal insulin dosage is usually made up of a combination of slower acting NPH Isophane and faster acting regular crystalline insulin The slow acting insulin begins to react in 1 hour peaks in 8 to 12 hours and is gone within 20 to 24 hours The other regular insulin is fast acting and starts working in about 1 2 hour and peaks from 2 to 3 hours later being completely used in 4 to 6 hours Table 1 Glucose Insulin Exercise Figure 1 Factors Affecting Glucose Balance Table I INSULIN TYPES 1 Rapid acting Takes effect 0 5 to 1 0 hrs Most effective 2 0 to 3 0 hrs Depleted 4 0 to 6 0 hrs 2 Intermediate acting Takes effect 5to 1 0 hrs Most effective 5 0 to 7 0 hrs
50. gs insulin dosages dates and remarks The data for the glucose trend analysis graphs are extracted form this table 3 Foodex contains food composition records for the diabetic food exchanges This table is used as both a reference and as a lookup table for meal planning 30 Foodcomp contains the USDA Home and Garden Bulletin 72 This contains over eight hundred food composition records used as a reference source Mealrecs contains patient menu records Dictionary a reference dictionary that contains useful medical terminology Exercise contains information on caloric expenditures for specific body weights and exercise activities used as a reference source Profiles contains information on a patient s individual menu profile Menudate contains the date the menu was prepared and lookup data from the Foodex relation 2 The Model Base Diabetes Support Systems s model base consists of graphical display models that support glucose trend analysis The models were constructed using Paradox s internal graphics generator and are supported by data contained in the Logbook relation Access to the model base can be accomplished in one of two ways 1 Ad hoc using Paradox s query by example feature Ad hoc trend analysis is only available when operating directly under the supervision of the Paradox 3 0 DBMS Predefined queries that are embedded in the stand alone application under trend analysis select
51. gure A23 Menu Design 15 to LE L G gt mM O 50 0 gt O CODES Protein Milk Bread Starch Fruit Vegetable Oil Fat Mixed Free Foods Breakfast Morning Snack Lunch Afternoon Snack Dinner Evening Snack Optional A table lookup function used to enter data from the Foodex relation into the MealRecs relation This is activated when the cursor is placed on the Food field A table lookup function used to select and enter the value for the Day field This copies the selected day value from the Auxiliary Days relation into the MenuDate Day field table lookup function used to select and enter the value for the Meal field This copies the selected Meal value from the Codes relation into the MealRecs Meal field Keyboard entry is required for the Date and Units fields A screen message located at the top of the form prompts the user to select the F2 key to complete the data entry process ESC to cancel or Ctrl U to undue the last changes Cursor movement is controlled as previously described However some additional capabilities are provided by the following keys The F3 and F4 keys allow the user to move the cursor from one embedded form to another This allows the user to activate the data entry function for the selected form Validity checking is provided in two ways first through embedded validity check settings and second through the auxiliary table lookup functions described in the Operations section above
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53. he competition DBase IV Enable etc in software comparison reviews conducted by the leading periodicals Miastkowski and Baran 1989 and Personal Computing Buyer s Guide Paradox 3 0 is a microcomputer based relational database management system It is compatible with both the DOS and OS2 operating systems It supports stand alone as well as network operations The software package consists of primarily two individual programs Paradox 3 0 DBMS and the Personal Programmer Three auxiliary programs Custom Configuration Data Toolkit Entry and Pal Programming Language give the builder access to more advanced procedures for customizing applications Borland also provides a supplementary package Paradox Runtime that allows programs that are developed with Paradox and or the Personal Programmer to execute as stand alone applications 26 Paradox 3 0 is a menu driven system designed for use by individuals at all levels of experience No programming expertise is required to develop applications since Paradox has its own application generator However applications can be significantly enhanced through the use of Paradox s Ascii based Pal Programming Language and the Data Entry Toolkit Paradox objects tables forms reports and graphs are constructed within the Paradox Program A flexible form and report generator provide the means to design customized products Both support linked unlinked and single multi table presentations Paradox offer
54. hich are numbered from left to right for clarification purposes The second digit is the menu level and the third digit if present is the menu selection mumbered from left to right An example would be 2 3 1 the first number 2 refers to the Main Menu selection Patient Records through which the selection is reached The second digit 3 indicates the selection is at the third menu level and the third 1 digit refers to the first menu item Update Patient on that level 32 1 The Main Menu The main menu provides access to all of the Diabetes Support System s menu selections and associated forms reports graphs and functions It allows the user to select one of six menu selections Figure 3 1 1 zel 3 1 4 1 Sel 6 1 7 1 Electronic Logbook Patient Records Reports Nutrition Exercise Dictionary Help Leave a Representations Screen presentation of Main Menu selections b Operations Each menu item provides access to the second level menu selection items c Memory Aids Menu selection descriptions for each item appear when the selection is highlighted On line help is also available d Control Mechanisms The menu selections and Leave selection exits program 1 1 Electronic Logbook Selecting Electronic Logbook from Main Menu provides access to second level selections Figure 4 1 2 1 Update Logbook 1 2 2 Trend Analysis 1 2 3 Help a Representations Screen presentat
55. ically scaled based on the highest value present in the sample The X axis displays the dates A key is provided that is used to differentiate the glucose readings by meal A blank screen is presented to the user until the graph is displayed hiding the selection and background steps Figure 7 38 By Day 3 Day Trend 7 Day Trend 14 Day Trend Help Figure 6 Electronic Logbook Level Four 39 ot Q a E E 5 ass 2 SSAA no wn SS Three Day Trend Analysis Figure 7 40 4 1 Nutrition Exercise A main menu selection item that provides access to the five second level menu selection items Figure 8 4 2 1 Nutrition 4 2 2 Exercise 4 2 3 Reports 4 2 4 Help 4 2 5 Leave a Representations Screen presentation of a Main Menu selection items b Operations Selects menu item c Memory Aids A menu selection description and on line help is provided d Control Mechanisms The ENTER key activates the menu selection 4 2 1 Nutrition A second level menu selection item providing access to four third level menu selection items Figure 9 4 3 1 Food Exchanges 4 3 2 Meal Planning 4 3 3 USDA Food Values 4 3 4 Help a Representations Screen presentation of third level menu selection items b Operations Selects menu item c Memory Aids A menu selection description and on line help 41 Nutrition Exercise Nutrition Exercise Reports Help Leave Figure 8 Nutrition Exercise Level Two
56. ill allow the dietician to maintain only the information pertaining to diet on another computer or only access the portion needed This feature will give a Type Il diabetic a stand alone Nutrition Exercise section that would be of most use to him B PARADOX 3 0 PROBLEM AREAS AND ADVANTAGES 1 The Advantages The advantages of Paradox 3 0 far outweighed the disadvantages As previously stated in chapter HI the Paradox system was chosen because it fulfilled all of the requirements for a relational data base system that supported a programming language and had graphic capabilities The major advantage of using a fh generation language 4GL is that it provides the user with the ability to develop a complex and sophisticated data management system without large amounts of programming experience The power of Paradox facilitated prototyping by allowing the basic system to be developed quickly This enabled the prototype to go through three iterations in less than four months including a three to four week leaming phase This was further enhanced by the use of the PAL programming language This was used to write code to perform specific 50 functions and add enhancements to the final product The combination added greater flexibility and allowed a more comprehensive application to be developed Another advantage of Paradox 3 0 is that once a system application has been developed it can be run as a stand alone system with the soon to be released Ru
57. in tabular form The TAB and arrow keys are used to move from field to field The PgUp PgDn keys will scroll through the table a page at a time Press F2 to return to the Main Menu h Level Two Structure 4 2 2 Exercise The Exercise selection allows the access to exercise planning information through the following sub menu Figure A25 95 USDA Food Values View USDA Bulletin Figure A24 Nutrition Exercise Level Four 96 Exercise View Edit Exercise Chart Figure A25 Nutrition Exercise Level Three om 4 3 5 View Edit Exercise Chart 4 3 6 Help i Level Three Structure 4 3 5 View Edit Exercise Chart This selection will allows the user to view or edit the Exercise Chart The screen displays a form that contains exercise activities and caloric expenditure per hour based on body weight The Up Down arrow keys will scroll through the records one at a time PgUp PgDn keys scroll by page The TAB and Right Left arrow keys move the cursor from field to field horizontally F2 will complete the session ESC cancels the session and CTRL U will undo the last changes Figure A26 J Level Two Structure 4 2 3 Reports Allows the Food Exchange Charts Menus USDA Food Composition Reports and the Exercise Chart to be printed This selection provides access seven different reports The source data for these reports includes 1 Food Exchange Reports American Diabetes Association 1988 McMahon and Travis 1984 and Ne
58. ion of Main Menu level menu selections 33 SUO OTOS NUON UDN eindia AD0 T dieH IDGOJ2IG CSJDCxa UOJI TIAN sj10doy Ppiosey JUOEJIDA 100807 2100112013 34 Electronic Logbook Trend Analysis Figure 4 Electronic Logbook Level Two 35 Operations Each menu item provides access to the second level menu selection items Memory Aids Menu selection descriptions for each item appear when the selection is highlighted On line help is also available Control Mechanisms The menu selections and Leave selection exits program 1 2 2 Trend Analysis Second level menu selections that access third level trend analysis selections Representations Screen presentation of second level menu selections Operations Controls access to three third level menu selection items Memory Aids A menu selection description appears when selection is highlighted On line help selection is available Control Mechanisms The ENTER key selects menu selection 1 2 2 Trend Analysis A second level menu selection that allows the user to access the glucose logbook relation through a query that prompts the user for the patient s last and first name The user is then provided access to the third level menu selections that support trend analysis The third level selections include Figure 5 1 3 1 By Day 1 3 2 By Meal 1 3 3 Help a Representations Screen presentation of second level menu selections b Operations
59. ions 3 The Interactive User Dialogue The application provides an interactive user dialogue through menu driven displays and on line help functions The menu structure uses Paradox style menu conventions This menu structure was designed and constructed using the Paradox Personal Programmer Help screen displays were installed by the builders Help selections are available at each menu level to guide the user 31 The menu structure controls the access to application s database and model base and guides the user through the system It also allows the user to select a variety of functions The Appendix contains the complete menu hierarchy along with associated menu selections D REPRESENTATIONS OPERATIONS MEMORY AIDS AND CONTROL MECHANISMS As previously stated the ROMC technique was applied to design the Diabetes Decision Support System This section examines the application s organization and functions using ROMC conventions The discussion will focus on the systems Main Menu structure and two of the more complex modules Trend Analysis accessed through Electronic Logbook and Design Menus accessed through Nutrition Exercise For a more comprehensive description of the entire system refer to the user s manual in Appendix The menu numbering is for clarification only The convention used will allow the reader to identify where the selection is located in the menu hierarchy The first digit refers to the main menu select w
60. ist s office This will allow the system to be evaluated under normal operating conditions With the results from the beta testing the final enhancements or changes can be added to the system At that time the final versions of the documentation can be completed 33 APPENDIX USERS MANUAL A PROGRAM OVERVIEW The Diabetes Support System DSS is designed to enable both the physician and the diabetic to better manage diabetes The physician is able to use the DDS system to maintain patient records and as an teaching aid for diabetics The diabetic can use the system in the home to help with blood sugar control and monitoring The DSS strategy is to allow the user a unified system that is both flexible in its breadth and yet simple to use By having all the information located in one place the user can easily obtain the needed information to maintain a proper glucose balance A menu type system was used to reduce the required leaming time The menu numbering is for clarification only The convention used will allow the reader to identify where ie selection is located in the menu hierarchy The first number refers to the main menu select which are numbered from left to right for clarification purposes The second number is the menu level and the third number if present is the menu selection numbered from left to right An example would be 2 3 1 the first number 2 refers to the Main Menu selection Patient Records through which the sele
61. its S Vitamin C in milligrams 6 Thiamine 7 Riboflavin 8 Niacin 4 3 13 Minerals This report contains 1 Food Description 2 Household measure 3 Calories 4 Calcium in milligrams 5 Phosphorus in milligrams 6 Iron in milligrams 7 Potassium in milligrams 8 Sodium in milligrams 9 Percent water 5 Dictionary This selection provides the user with an alphabetical listing of diabetic and medical terms and the corresponding definition This concludes the User s Manual 106 BIBLIOGRAPHY American Diabetes Association and American Dietetic Association Exchange Lists for Meal Planning 1986 Boehringer Mannheim Corporation Merlin Diabetes Data Management System User s Manual Version 1 0 1988 Buyer s Guide Relational Database dbase III Plus Paradox DataEase R Base for DOS Professional Oracle Advanced Revelation Special Personal Computing v 12 pp 173 178 November 1989 Ellenberg M Chronic Complications of Diabetes Mellitus NY State Journal of Medicine pp 2005 2014 December 1979 Feder Arlene S Counting on Computers Diabetes Forecast pp 38 42 November 1988 McMahon Paula R D and Travis Luther B M D Your Daily Meal Plan University of Texas Medical Branch Galveston Texas 1988 Miastkowski Stan and Nick Baran Paradox 3 Neither Enigma Nor Riddle Byte pp 109 111 February 1989 Netzer Corinne T The Complete Book of Food Counts Dell Publishing Co Inc New
62. lop gangrenous infections that often result in the amputation of limbs Secondary infections and other disease related complications claim the lives of 20 000 diabetics each year Finally terminology is another problem associated with any medical condition Diabetes is no exception and in fact requires knowledge of a wide variety of medical terms covering many aspects of the body and a number of diseases There are also a number of terms from dietetic and exercise terminology that need to be understood Terminology can become a barrier to understanding by individuals as well as between medical personnel and patients Figure 2 D ONSET AND TREATMENT As with any disease effective treatment for Juvenile Onset Type I diabetes mellitus begins with proper diagnosis The disease typically appears in the growth and puberty years however onset may occur at any age Symptoms often appear quite dramatically and in many cases the patient may require initial hospitalization Frequently in small children the disease becomes critical before a doctor is consulted and requires hospitalization until a positive diagnosis is made and the patient is stabilized The causal factors may be genetic and or precipitated by an unknown factor The primary determinant of Type I Diabetes is the inability of the patient s pancreas to produce insulin Once this diagnosis is confirmed the attending physician usually an endocrinologist conducts a series of tests to est
63. lucose diagnostic information into a single source interactive software 29 application The system was constructed for use on any IBM compatible personal computer running DOS 3 1 or higher 640K of RAM and secondary storage of 1 megabyte or a hard disk drive to run the application The Diabetes Support System contains two applications that were developed independently one for medical diagnostics and reference and one that supports dietary and exercise decisions This provides the users with the capability of installing and running either program as an independent stand alone application or as a single entity For the purpose of discussion in this paper the application is described and examined as one program C SYSTEM COMPONENTS The Diabetes Support System consists of the three characteristic components that identify a decision support system a database model base and an interactive dialogue sub system Sprague and Carlson 1982 1 The Database The database incorporates seven primary relations that provide reference trend analysis and storage functions for the system s records In addition several auxiliary relations serve as validity checking mechanisms that are activated through table lookup functions The primary relations consist of 1 Patient Records containing individual patient records personal information diet and medical history 2 Logbook an electronic logbook containing individual patient glucose readin
64. me and then for the patient s first name The user will now see a multi view table consisting in the top half the patient s name Social Security Number date of next visit and date of last visit In the bottom half of the screen is a table in tabular form consisting of the date insulin dosages glucose readings and a remarks section The insulin dosages are grouped by time of day ie breakfast lunch dinner dinner and night time with the types and amounts of insulin regular or NPH The glucose readings are also broken down by time of day in the same manner as the insulin dosages A remarks section is provided to allow the user to indicate reasons for deviations or exceptions to either insulin dosages or high or low glucose values The glucose logbook can be updated using normal editing keys such as delete and backspace Moving from field to field is accomplished by either the arrow keys or more easily with the ENTER key The logbook is keyed on the date and are listed in order of date The Page Up and Page Down keys are used to move vertically through the logbook records to find update or review a specific date Figure A3 1 2 2 Trend Analysis The Trend Analysis selection first queries for the patient s name to select the appropriate records This leads to a third level sub menu Figure A4 1 3 1 By Day 1 3 2 By Meal 60 6851 I 6861 I 1 abed prady senuep PISTA JXIN 3 1514 3587 938 9951 4 y8l 350919 3503019
65. mitment to the user s decision making style This is extremely significant when considering the fact that most users cannot adequately describe their decision making process Sprague and Carlson note that users most often use visual cues pictures graphs and charts when formulating a decision Based on this knowledge ROMC provides the perfect vehicle for analyzing user requirements for decision support systems Applying these conventions to the Diabetes Support Systems produced the general system requirements listed in Table IV C SYSTEM RECOMMENDATIONS AND DESIGN CONSIDERATIONS Interviews with diabetics and physicians in conjunction with observations and discussions at Stanford Childrens Medical Clinic indicate that there is interest in a computerized diabetes system provided the following basic design considerations are maintained 1 Automate the collection and storage of glucose readings and insulin dosages 2 Provide graphical displays of blood glucose levels for trend analysis exception reporting and diagnostic control 3 Provide the ability to display print food exchange charts as an aid for meal planning 23 4 Provide an automated menu planning function This will allow the user to select foods from a food exchange database and input those values directly into Table IV ROMC Systems Requirements Representations 1 An electronic logbook for storing insulin doses glucose readings 2 Trend analysis bar scatter graph
66. n Time program This will allow the system to be run without the underlying Paradox program 2 Problem Areas Several problems were identified with the use of Paradox 3 0 First was the initial learning curve that is encountered when dealing with any unfamiliar software product As with all new and sophisticated software there is a large learning curve to overcome This was expected to some degree A second problem related to the first is that Paradox actually consists primarily of three main programs the DBMS the Personal Programmer and the PAL programming Language Although related and similar each necessitates a separate leaming curve The PAL programming language was structured somewhat like Pascal but it contained a number of command abbreviations that were not well documented A third problem that was encountered was the quality of the vendors support documentation and reference manuals Although comprehensive in nature they were poorly organized and lacked a complete glossary of error messages This increased the difficulty of debugging A library of sample PAL applications would be most welcome also At the time development was started only information from Borland was available 51 The database management system was easy to leam and use but had a large number of features that took time to master The DBMS was used to build the database tables forms and reports The capabilities of the program were excellent the query by
67. nce of fats carbohydrates and proteins When to exercise and how much These are only a few of the daily decisions that need to be made With the amount and varieties of knowledge needed a decision support system would help these people make the proper decisions and can be of enormous value in the fight against a serious and tragic disease which robs thousands of people each year of quality of life as well as life itself This paper will address how such an approach can be applied to diabetes B WHAT IS DIABETES Every cell of the body requires energy to maintain life and carry on its specific functions This energy is derived from glucose Glucose or sugar is obtained from carbohydrates contained in foods and is carried by the blood stream to the cells In order for the glucose to be absorbed into the cells the hormone insulin is required Insulin and a number of other hormones are produced in the pancreas The sites where the insulin is produced are called beta cells Insulin is essential in regulating the metabolism of glucose into the cell Travis 1985 Diabetes has been divided into two major types each of which has a number of terms used to describe them The first type is called Type I insulin dependent or juvenile on set diabetes Type I diabetes frequently appears in children although it can appear at any age Type I diabetes is the primary focus of this project The second form of didier is Type II or adult on set diabetes
68. nd body weight c Consistent food intake Of the three major regulatory factors diet insulin and exercise food and insulin have the most dramatic effect on glucose levels It is impossible to stabilize insulin levels if food intake fluctuates from day to day 3 Food Exchanges Charts a The Exchange Diet methodology This approach to diet planning divides foods into six categories on the basis of fat protein and carbohydrate intake It provides standard measures for food serving sizes Each measure is described in terms of total calories and nutrient content All foods contained in a particular category can be exchanged for any other food in that category on a One for one basis For example 1 slice of bread or 3 4 cup of dry cereal both equal 1 Bread Exchange The six major food exchanges are 13 e Milk Exchange e Fruit Exchange Vegetable Exchange Starch Bread Exchange Protein Meat Exchange e Fat Exchange b Carbohydrate intake Carbohydrates have the most profound effect on blood glucose levels and insulin requirements This is due to the fact that carbohydrates are composed of sugars glucose and or derivatives of Therefore it is imperative that carbohydrate intake stay constant Three of the six food exchanges contain significant amounts of carbohydrates Starch Exchange e Fruit Exchange Milk Exchange c Protein and fat intake These two components are required for proper nutrition However they d
69. nsulin dosages diet and exercise programs can be maintained If not within normal range the diabetic must discover if a trend exists b If the trend indicates a very low value less than 60 ml dl consistent low readings either over a period of time or repeatedly at the same time daily action should be taken A number of choices must be made depending on which of the three indications exist A very low reading may be an indication of Hypoglycemia and the glucose level must be raised usually by consuming a small amount of sugar immediately If the readings occur repeatedly then a modification of the insulin dosage by lowering one of the types of insulin may be required c If the readings indicate glucose levels above normal greater than 150 ml dl modifications of dosages and types may be required by increasing either amounts or types of insulin With high readings concern arises about Hyperglycemia and Keto acidosis Urine samples may need to be monitored for Ketones 2 A suitable diet plan a The individuals food preferences This is an extremely important consideration Successful dietary control hinges on acceptance by the diabetic Every effort should be made to accommodate food preferences within the allowable constraints imposed by the disease b Age sex and body weight The dietary goal is to develop a meal planning methodology that provides the nutritional and total caloric intake for an individual based on age sex a
70. nt This requires the diabetic to know not only the number of calories a food item contains but also the makeup of these foods In order for the diabetic to manage a proper diet food exchange charts are used in meal planning to achieve the balance required Food exchange charts give group foods by type relative makeup and portions This information along with calorie charts and dietary plans gives the diabetic a basis for daily food intake requirements Another important factor in regulating the amount of glucose in the blood stream is exercise Daily exercise is important for a number of reasons One reason is that exercise is important in maintaining body weight Obesity compounds the problem of diabetes by increasing the amount of insulin required to maintain glucose levels and is a major contributor to Type II diabetes High levels of fat in the blood stream also can contribute to atherosclerosis the building up of deposits in the arteries Exercise increases the body s ability to use glucose and reduces the need for insulin Therefore exercise is extremely beneficial to the diabetic But at the same time exercise must be closely monitored to avoid an insulin reaction due to too low a glucose level Diabetes affects the body in many ways especially the circulatory system As a result poor control diabetics have a significantly higher incidence of coronary disease liver damage blindness and poor blood circulation Extreme cases may deve
71. o not directly affect glucose level in the blood Travis 1985 4 Exercise management a Lack of exercise can cause an increase in body weight thus causing an increase in the amount of insulin required Cholesterol levels are affected by the amount of exercise With inactivity cholesterol levels may increase and increase the risk of arterial disease b Excessive exercise can cause the insulin to be absorbed too quickly causing a drastic drop in blood glucose levels and leading to hypoglycemia These are only a few of the decisions required to maintain a diabetic every day many of these issues can be critical The diverse nature and frequency of these decisions can be overwhelming for both the diabetic and the health care professional especially if not a specialist in the field An automated system could vastly improve 14 the quality of diabetic care over the present mostly manual system by providing a number of features to aid the diabetic in the management and control of this disease The better the control of glucose in the blood stream the less likely there will be secondary complications in the future The physician or a health care professional and dietician teach the diabetic the basics and some of the skills of how to maintain effective control These instructions include the principles of the food exchange diet methodology for blood glucose control calorie intake diet control and menu preparation Exercise programs may also b
72. o the Main Menu 57 8 F3 F4 keys used to move the cursor from one embedded form to another within a multi table form 9 F9 used to activate the editing mode 10 Pressing CTRL U will undo the last changes that were made during an edit or data entry session 11 Pressing CTRL BREAK will stop a report from being printed 2 Selecting Menu Items To choose a menu selection either type the first letter of the selection or use the arrow keys to highlight the selection and press the ENTER key To cancel the selection or move to the next higher menu level press the ESC key C MENU SELECTION DETAILS 1 Electronic Logbook Menu Structure The Electronic Logbook is the master record of glucose readings The logbook is indexed on the patient s social security number SSN and an individual s file is accessed by the patient s name The glucose readings are further indexed by date The second level sub menu of the Electronic Logbook consists of three selections which allow the user to update and analyze glucose information and obtain help information from the help menu The sub menu consists of Figure A2 1 2 1 Update Logbook 1 2 2 Trend Analysis 1 2 3 Help 58 Electronic Logbook Trend Analysis Figure A2 Electronic Logbook Level Two 59 a Level Two Structure 1 2 1 Update Logbook This selection allows the user to select an individual s glucose logbook The user is queried to enter the patient s last na
73. of his life The way to do this is through information The problem is the diverse nature of the information There is no central location where the individual can go for information about diet food exchanges meal plans exercise and medical terms Even at the clinic the diabetic may need to see a physician a dietician and the nursing staff to answer various questions There is also the problem of maintaining the records needed to track glucose readings external influences that affect them insulin dosages time and location of injections An informed patient is a healthier patient reducing the medical burden and saving financial resources Some of the current systems available will be reviewed below B THE MANUAL SYSTEM The current system used by most diabetics is a manual system A written log is maintained to record glucose readings times of the readings and insulin dosages A record is also needed to record daily occurrences such as meals exercise and any variations such as illness or stress A food exchange booklet and calorie charts are needed to plan meals and monitor food intake C COMPUTER BASED SYSTEMS At this time there are four data management systems available to the public these systems are listed in Table II Feder 1988 A review of some of the available computer based systems revealed rwo important points First there is a move towards this type of system with new systems being marketed almost monthly Second
74. ok with a query capability is needed to provide both the patient and physician the ability to quickly spot trends and areas where action is required On a daily weekly and or monthly basis the patient can easily review glucose reading insulin dosages and changes for trends to better control and maintain tight control The physician in the short time available during an appointment can better determine what is needed and give positive reinforcement where appropriate This will give more time for personal contact and to answer specific questions thus making the visit more meaningful for both the patient and doctor A central meal planning capability is also needed to gather all the different information needed together for consistent and effective dietary control There are so many diverse requirements involved in meal planning that a central meal planner could improve control immensely It will also provide a record for the physician and dietician to make fine adjustments to the individual s diet The same philosophy applies to an exercise planner The easier and more accurate it is for the physician the better the medical care The easier it is for the patient the more likely he is to stick to the treatment program As a diabetic leams how to manage the disease he gains confidence and the calls to his physician decrease But there still is a requirement for information As a diabetic becomes more informed he wants to know more and take charge
75. porating changes 2 The Development Process Within the framework of the DSS approach the project was divided into three phases 1 A preliminary feasibility study Based on interviews with prospective users physicians medical support personnel and diabetics a literature review and interviews with commercial software developers it was concluded that the proposed system was feasible if new software technology was applied 2 System analysis and requirements definition From the feasibility study it was determined that the need existed for this system On that basis more interviews and an analysis of the current system were conducted The analysis identified several decisions that could benefit from a Decision Support System 3 Prototype development Using this technique and ROMC conventions an initial paper prototype and design specifications for the system were identified Once approved the coding phase was initiated using a sophisticated fourth generation commercial software package The iterative process was continued through the third iteration 22 B ROMC AND SYSTEM ANALYSIS ROMC provides a process independent methodology for defining analyzing designing and constructing decision support systems Sprague and Carlson 1982 view this feature as being among the most important characteristics of the ROMC approach Process independence allows the builder to analyze and establish the user s requirements with no prior com
76. roximately 2 000 000 people in the United States that have Diabetes Mellitus Diabetes occurs when the body has insufficient quantities of insulin to process glucose for cell energy It is characterized by a build up of glucose in the blood stream and urine As a result all parts of the body are exposed to these high levels which can lead to serious complications chief of which are macrovascular related diseases such as atherosclerosis and microvascular diseases that affect every organ Macrovascular diseases like heart disease are a leading cause of death in diabetics Ellenberg 1979 Because of these complications maintaining glucose levels as close to normal as possible is essential in the treatment of diabetes The Veterans Administration VA and military hospital systems are among the largest medical systems in the world The uniformed services medical community alone treats thousands of dependents with diabetes each year With the severe shortage of medical personnel in both the military and the Veterans Administration only the larger military hospitals and VA facilities have endocrinologists on staff Many hospitals such as Fort Ord have only a part time civilian doctor that holds clinics for diabetics once a quarter The key to controlling diabetes is close monitoring of glucose levels With frequent monitoring fluctuations in glucose levels can be identified early Using these trends such as recurring highs or lows steps can be
77. s depicting glucose levels screen displays and printed graphs 3 Food exchange charts for menu planning screen displays and printed reports 4 A menu planning template screen display design workspace 5 Printed daily menus 6 Food composition charts for reference screen display and printed reports 7 A medical reference dictionary screen display 8 Exercise activity charts depicting caloric expenditure screen display and printed report Operations The following functions view edit data entry graph delete insert save query print and table lookup Memory Aids Online help screen message prompts menu selection descriptions a workspace for menu planning table lookup and various views of the data base Control Mechanisms Menu driven control data validity checking standard function key assignments and table lookup capability 24 dailv menus that can be stored and or printed The menus should provide calorie nutrient serving size and exchange information 5 Provide a user friendly ad hoc dictionary of relevant medical and diabetic terms 6 Provide exercise charts that display caloric expenditure for various activities based on body weight D SOFTWARE SELECTION To be successful and meet the needs of the user the system had to consolidate a variety of diet exercise and medically related diagnostic information as well as provide a wide range of functional capabilities During the feasibility study
78. s the flexibility of performing data entry update modification and output functions via custom forms and reports or directly to from the relations themselves The Paradox Personal Programmer provides the means to generate Paradox style menus and allows the user to connect objects previously constructed in Paradox DBMS to a variety of menu functions The available menu selection actions include view edit report dataentry query graph print and scripts play executes custom procedures The application can also be used to generate prototype code that can be modified and enhanced through the use of Pal programming language Query by example QBE allows virtually unlimited ability to select items from the tables and create customized views of individual or multiple tables within the DBMS However for stand alone applications queries must be predefined This requires close user builder communication to ensure the useful views are constructed Additionally the QBE feature allows the user to select and sort data in individual fields in ascending or descending order 27 In summary Paradox 3 0 is an extremely flexible and comprehensive fourth generation DBMS and software development tool However it does have some limitations discussed in chapter five Once the program was selected the design phase was finalized and construction was started 28 IV SYSTEM DESIGN A INTRODUCTION The Diabetes Support System was designed to enable
79. tant details about caloric intake and diet restrictions Again a remarks section is available to add patient specific flexibility This selection also allows the user to add a patient to the database The user will be presented with a blank multi record form The user will then fill in the background data for a new patient The user can enter data ESC to quit without saving data or Undo what has been entered To move from field to field the ENTER key is used After the data has been entered the user press F2 to save the new record to the database For a description of the form see Individual Record below Figure A10 Patient Record Detail If the Update Logbook selection is chosen the following selections are provided Individual Record This selection queries the user for both the last and the first name of the desired record The name must be capitalized in order to find the correct record 71 F2 Cosplete edit Esc Cancel edit Ctrl U Undo last change Ins insert a recor Patient Data Nase Data y Sample SSN 1227 45 6782 Age ES Address 124 Dar St City Your Town State Medical History Last Updated 25 May 89 Age cf Diabetes On set le Ideal Range 88 to 128 al dl Hypoglvcesic Below 48 al di Tips 12345 5002 Teld 403 125 456 Hb Ric Last eo Date 1 Feb 85 Last Visit 1 Jan 8 Previous 18 1 Date 1 Dec 6 Nest Visit d Apr 59 Rec 4 Type Insuian be Huaulin NPH Dietary Information ht od In 57 4
80. the side effects of diabetes This paper will address how such an approach can be applied to diabetes resulting in better medical care and decrease the demand on a stressed medical system TABLE OF CONTENTS I INTRODUCTION RO ee 1 A BACKGROUND O O O raiar a 1 B WHAT IS DIABETES a cs L s 3 C TREATMENT OF DIABETES 4 D ONSET AND TREATMENT 9 H SYSTEM ANA SE 7 ee 12 A THE NEED FOR INFORMATION 12 B THE MANUAL SYSTEM 17 C COMPUTER BASED SYSTEMS 17 HI DEVELOPMENT TOOLSE er oo ae 21 A METHODOLOGY SS ee 21 B ROMC AND SYSTEM ANALYSIS 23 C SYSTEM RECOMMENDATIONS AND DESIGN CONSIDERATIONS 20 Q aaa 23 D SOFTWARE SELECTION 25 IV SYSTEM DESIGN O ee en 29 A INTRODUCTION et P s P DON 29 iv D REPRESENTATIONS OPERATIONS MEMORY AIDS AND CONTROLIMECHANISMS T eeen ee 32 DHDISCUSSIONPANDICONCEEUSIONS 48 A USES OF THE DIABETES SUPPORT SYSTEM 48 B PARADOX 30 PROBLEM AREAS AND ADVANTAGES 50 C THE DIABETES SUPPORT SYSTEM CONCLUSIONS 52 A A A ee eene 53 EE ee sd du ee ee ee 54 EO VER NIE eee ee eee eee eee ee 54 ee PC ORMT OM ECHANISMEN eee es 57 CE US ELECTION DETAILS ee ene eee 58 Las LOG UT q RR TT 107 REP TION LIST oa 109 L INTRODUCTION A BACKGROUND There are app
81. tzer 1988 2 USDA Food Value Reports USDA Home and Garden Bulletin Number 72 1981 These reports are accessed through the following sub menu selections Figure A27 4 3 7 Food Exchange Charts 4 3 8 All Charts 98 F2 Data entry completed Esc Cancel data entry Ctri U Undo last change EXERCISE CHART Calories Burned Per Hour for Selected Activities SETE E re ee ee eee me cas am Activity 110ibs j 130 bs 150lbs L dl s 1701bs 1901bs 2151bs BACKPACK ING 400 470 540 600 695 770 BASKETBALL 415 485 565 635 715 800 CANOEING 130 155 180 205 230 260 CLIMBING 360 420 485 350 620 710 420 480 420 475 935 600 210 235 265 295 59 290 320 365 515 580 650 730 455 315 575 655 350 390 440 300 360 405 455 515 270 305 340 399 DANCING FAST 310 365 DANCING SON 155 186 FISHING 185 22 GARDENING DIGGING 375 445 GARDENING MOWING 355 395 GOLFING 260 300 GYMNASTICS 280 315 HORSEBACK RIDING 200 235 IRONING 100 115 585 690 CYCLING RACING 310 600 690 780 870 980 130 795 150 170 190 CYCLING LEISURE 240 265 j 305 365 es w ms so 105 ne 900 1005 1145 JUDO KARATE Figure A26 View Edit Exercise Charts 29 Reports Food All Your Fats Nutrients Vitamins Help Exchange Charts Daily Charts Menu Figure A27 Nutrition Exercise Level Three 100 4 3 9 Your Daily Menu 4 3 10 Fats 4 3 11 Nutrients 4 3 12 Vitamins 4 3 13 Minerals 4 3 14
82. ulletin 72 through the following sub menu Figure A19 4 3 1 Food Exchanges 4 3 2 Meal Planning 4 3 3 USDA Food Values 4 3 4 Help 85 Nutrition Exercise Nutrition Exercise Reports Help Leave Figure A18 Nutrition Exercise Level Two 86 Nutrition Food Meal USDA Help Exchanges Planning Food Values Figure A19 Nutrition Exercise Level Three 87 b Level Three Structure 4 3 1 Food Exchanges The Food Exchanges selection provides access to the food exchange database through a sub menu that consists of Figure A20 44 1 View Edit Exchange Charts 44 2 DataEntry 443 Help c Level Four Structure 4 4 1 View Edit Exchange Charts The user will queried to enter the food exchange to be viewed or edited Select and press ENTER The screen will then display a form that contains foods listed in the selected exchange The Up Dn arrow keys are used to scroll through the form one record at a time The PgUp PgDn keys scroll by page The TAB and Right Left arrow keys move the cursor from field to field horizontally F2 will complete the session ESC cancels the session and CTRL U will undo the last changes made Figure A21 4 4 2 DataEntry This selection allows new records to be entered into the Food Exchange database When selected a blank multi record form will appear on the screen Data must be entered in each field The cursor in moved through the form by using the same keys as described above 88 Foo
83. users with limited computer experience the freedom to use the system with the minimum amount of preparation It provides physician medical staff personnel and diabetic users with a decision support system that features the following integrated software applications 1 The application provides an electronic logbook for recording insulin dosages glucose readings as well as several trend analysis functions 2 patient record selection that allows the medical staff to access patient records and specific medical background and diet information 3 A nutrition application that contains a database containing FDA food charts and diabetic food exchange charts that can be accessed for planning menus and or determining the nutritional content fats proteins carbohydrates etc as well as calculating caloric content 4 An exercise application containing a database for determining caloric expenditures for various aerobic exercise activities based The caloric expenditures are based on age weight and sex B DESIGN OVERVIEW The Diabetes Support System application was designed as a specific decision support system It will provide information to structured and semi structured queries in support of physicians dieticians and diabetics for the purpose of monitoring and controlling diabetes It was designed as a comprehensive system that could consolidate decisions from the three major diabetes regulatory factors exercise nutrition and insulin g
84. y function for the selected form 3 The Tab and Arrow keys allow the user to move from field to field within the selected form 4 The F1 and F2 Keys allow the user to activate table lookup functions This is accomplished by placing the cursor on the following fields and pressing Fl SSN Day Meal and Food The F2 key completes the table lookup data entry function 5 The ESC key allows the user to cancel the editing session 46 6 Validity checking is provided in two ways a Embedded validity check settings b Auxiliary table lookup functions described above 7 The master form MenuDate enforces referential integrity by providing the following links a A one to many link from the MenuDate relation to the MealRecs relation The relations are linked on the key fields SSN and Date b A one to many link from the Menudate relation to the Profiles relation The tables are linked on the Key field SSN 8 The PgUp PgDn keys allow the user to move from one page to another 9 Pressing CTRL U will undo the last changes The forms and reports have been designed to aid the user in the input of data by having value range checks lookup tables and default value entries The value ranges will notify the user that a value entered is not in the range of possible values with a tone and will automatically go into edit mode until a value that is within range is entered Lookup tables are provided to aid in the entry of data by displaying a data

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