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Ii!.t.VAL POST:J^i:lj:/0.e.l'S SCHOOL MOHTEREY, GALirORNIA 93943-BOOB NAVAL POSTGRADUATE SCHOOL Monterey, California THESIS A Personal-Computer Based DSS For Diabetes Control and Monitoring by Richard A. Blow and Steven P. Albert September, 1989 Thesis Advisor. Approved Professor for public release; distribution is Moshe Zviran unlimited. T245589 NCL.\SSIED CURITY CLASSIFICATION OF THIS PAGE REPORT DOCUMENTATION PAGE REPORT SECURITY CLASSIFICATION lb RESTRICTIVE MARKINGS NCLASSIFIED SECURITY CLASSIFICATION AUTHORITY 3 DISTRIBUTION/AVAILABILITY OF REPORT Approved for public release; distribution is unlimited DECLASSIFICATION/DOWNGRADING SCHEDULE PERFORMING ORGANIZATION REPORT NUMBER(S) 6b OFFICE SYMBOL NAME OF PERFORMING ORGANIZATION 1 5 (li aval Postgraduate School Naval Postgraduate School 7b ADORESS(C/ty, State, and Z/P Code) Monterey, CA 93943-5000 looterey.CA 93943-5000 NAME OF FUNDING/SPONSORING IRGANIZATION b OFFICE a ADDRESS (Crty, State NAME OF MONITORING ORGANIZATION 7a applicable) M>DRESS{Crty. State, and ZIP Code) c MONITORING ORGANIZATION REPORT NUMBER{S) (If SYMBOL PROCUREMENT INSTRUMENT IDENTIFICATION NUMBER 9 applicable) 10 and ZIP Code) SOURCE OF FUNDING NUMBERS Program Element Ni TITLE (Include Security Claujfication) 1 PERSONAL COMPUTER BASED DSS FOR DIABETES CONTKOL AND MONITORING 2 PERSONAL AUTHOR(S) Blow, Richard, A and 13b TIME Albert, Steven, P. COVERED DATE OF REPORT 14 (year, month, day) September 1989 B 15 PAGE COUNT 115 SUPPLEMENTARY NOTATION he views expressed in this thesis are those uf the author and do n ovemment. 7 COSATI CODES 18 SUBJECT reflect the official policy or position of the TERMS fcont/nue on /•( e if necessary Department of Defense or the U.S. and identify by b/ock number) Diabetes Decision Support System ABSTRACT fcont/nue on 9 reverse ;/necessa'>dod/denf/fy by 6/ock number) many people The military medical system is one of the largest medical systems in the world, and of dependent diabetics As with most sections of the military, the medical community is imderstalTed. This results in adequate medical care for these patients The key to the treatment of diabetes is control of blood glucose levels and the )ntribuling factors, such as food and exercise. By controlling these factors large fluctuations in the glucose levels can be minimized. A decision jpport system that enables both the medical personnel and the patient to manage these factors could vastly improve treatment and mitigate the ide 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. Diabetes is a serious disease that affects •eats a significant number lost facilities lacking DISTRIBUTION/AVAILABILITY OF ABSTRACT Q ID jSCLASSifltP/UNLiMtTeP Q 21 SAMt ASWiPQWT ABSTRACT SECURITY CLASSIFICATION Unclassified 22b TELEPHONE (Include Area code) (408)6462489 FORM 1473, 84 MAR 83 APR edition may be used until exhausted Ail other editions are obsolete SECURITY CLASSIFICATION OF THIS PAGE UNCLASSIFIED Approved for public release; distribution is unlimited. A PERSONAL-COMPUTER BASED DSS FOR DIABETES CONTROL AND MONITORING by Richard A. Lieutenant Blow Commander, U.S.N.R. MS., CORPUS CHRISTI STATE UNIVERSITY, 1984 AND Steven P. Albert Lieutenant B.S., Commander, U.S.N. UNIVERSITY OF TENNESSEE, Submitted in 1977 partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN INFORMATION SYSTEMS from the NAVAL POSTGRADUATE SCHOOL ^^ SEPTEMBER 1989 ABSTRACT Diabetes system is is a serious disease that affects one of the largest medical systems number of dependent community is diabetics. understaffed. care for these patients. As many The and military medical treats to the facilities lacking adequate medical treatment of diabetes is control of blood glucose levels and the contributing factors, such as food and exercise. By these factors large fluctuations in the glucose levels can be minimized. support system that enables both the medical personnel and the patient to factors could vastly paper will address a significant with most sections of the military, the medical This results in most The key people. in the world, controlling A decision manage improve treatment and mitigate the side effects of diabetes. how these This such an approach can be applied to diabetes resulting in better medical care and decrease the demand on a stressed medical system. 6.1 TABLE OF CONTENTS I. INTRODUCnON j A. BACKGROUND B. WHAT C. TREATMENT OF DIABETES D. ONSET AND TREATMENT j n. IS DIABETES? 3 4 9 SYSTEM ANALYSIS A. j2 THE NEED FOR INFORMATION B. THE MANUAL SYSTEM C. COMPUTER-BASED SYSTEMS 12 17 17 m. DEVELOPMENT TOOLS A. METHODOLOGY B. ROMC AND SYSTEM ANALYSIS C. SYSTEM RECOMMENDATIONS CONSIDERATIONS D. IV. SOFTWARE SELECTION SYSTEM DESIGN A. INTRODUCTION 21 21 23 AND DESIGN 23 25 29 29 B. DESIGN OVERVIEW C. SYSTEM COMPONENTS D. REPRESENTATIONS. 29 OPERATIONS, 30 MEMORY AIDS CONTROL MECHANISMS V. DISCUSSION A. AND CONCLUSIONS AND 32 48 USES OF THE DL^BETES SUPPORT SYSTEM 48 50 B. PARADOX C. THE DIABETES SUPPORT SYSTEM CONCLUSIONS 52 D THE FUTURE 53 3.0 PROBLEM AREAS AND ADVANTAGES APPENDIX 54 A. PROGRAM OVERVIEW 54 B CONTROL MECHANISMS 57 C. MENU SELECTION DETAILS 58 BIBLIOGRAPHY INITIAL DISTRIBUTION 107 UST 109 INTRODUCTION I. BACKGROUND A. There are approximately 2,000,000 people Mellitus. when Diabetes occurs process glucose for cell energy. As blood stream and urine. which can lead levels is It in the body has the United States that have Diabetes insufficient quantities of insulin to characterized by a build-up of glucose in the a result, all parts of the body serious complications, chief of to are exposed which to these high are macrovascular related diseases, such as atherosclerosis, and microvascular diseases that affect every organ. Macrovascular diseases, diabetics (Ellenberg, 1979). like heart disease, are a leading cause of death in 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 largest medical systems in the world. TTie military hospital systems are among 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. frequent monitoring, fluctuations in glucose levels can be identified early. With Using these trends, such as recurring highs or lows, steps can be taken to correct them. Early and analysis of trends promotes tighter control. detection adjustments in insulin, diet and exercise to be made. health, may doctor and visits to the most physicians complications arising later At allows smaller prevent hospitalization. In addition to promoting good feel that tight control community and improve This Maintaining tight control reduces in life. of glucose levels will lead to fewer This will reduce the strain on the medical the quality of life for diabetics. (who the present time, both diabetics and medical personnel are not familiar with diabetes treatment) must manually study logbooks of glucose readings, diet plans, food exchange charts, and exercise tables patient's glucose maintenance programs. difficult to an effort to sustain their in This is time-consuming and it own is or their frequently 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 With sugar levels. trends sooner and this system, small hospitals, clinics and individuals could identify make needed changes. Diabetics and health care professionals must daily in the control and maintenance of diabetes. of insulin is required? How many calories to make numerous How much important decisions and what combination consume? Menus must be planned with the proper balance of fats, carbohydrates and proteins. When much? These need to be made. amount and are only a varieties of few of the daily decisions that to exercise and how With the 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 This paper will address as well as life itself. life, how such an approach can be applied to diabetes. WHAT B. Every IS cell DIABETES? of the body requires energy to maintain This energy functions. is derived from glucose. carbohydrates contained in foods and is carried life and cany on Glucose (or sugar), by the blood stream is the insulin number of other hormones is are produced in the pancreas. produced are called beta metabolism of glucose Insulin cells. specific to the cells. order for the glucose to be absorbed into the cells, the hormone insulin Insulin and a its obtained from The is In required. sites where essential in regulating the is into the cell (Travis, 1985). Diabetes has been divided into two major types, each of which has a number of The terms used to describe them. Type juvenile on-set diabetes. appear at any age. form of diabetes be Type dependent insulin Although is Type this system n fu^t type is In Type I or adult on-set diabetes. and can energy. As Without I, insulin dependent, or Type n diabetes may diet it can The second or may not and exercise. focused on insulin dependent diabetes, three of the four diabetes the cells, in their Type sometimes be controlled with immune Type n system, for diabetics. unknown TTie destruction of these beta celN re<;ults in by the pancreas. The called the primary focus of this projea. applications could be of significant use to cells is diabetes frequently appears in children, although diabetes I is I little reasons, destroys the beta or no insulin being produced insulin, the ability to transport glucose into the cell is lost. quest for energy, will use fat stores in order to obtain this needed fats are convened into energy, ketones are produced in the liver which build up in the which can This can lead to diabetic acidosis, a serious condition blood stream. 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 with daily injections of artificially produce insulin, I diabetics on an as-needed must manually maintain produced insulin. basis, diabetics as close to normal as possible, artificially. must As their glucose levels a result of not being able to try to keep their glucose levels, 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 individual and his or her life style. in diabetes and heart disease is Atherosclerosis develops at an accelerated rate such as the eyes, kidneys, gastrointestinal Diabetes is Microvascular the leading cause of death in diabetics. diseases affect the small vessels of the blood stream causing tract damage to the organs and circulation in the lower extremities. 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 controlled. using fast, Today, it is if blood glucose levels could be closely monitored and possible for diabetics to monitor their glucose levels at accurate and reliable self-testing procedures. their glucose readings with a range normal. home Individuals can then compare of clinically determined values that are considered With careful monitoring, a diabetic can adjust his/her daily insulin dosages to a level that will many keep blood glucose values within this normal range. and insulin factors can affect the delicate balance of glucose However, and exercise are among the most important of these regulatory factors (Figure Blood monitoring is a complex process which requires the Diet in the blood. management of 1). insulin dosages, insulin types and analysis of blood samples taken by the individual. are a number of regimens of blood monitoring and loose control of or 1 to 2 blood samples per day and more samples and two or more injections insulin injections, ranging individual takes a small sample of blood from reactive chemical test strip to determine the stream. TTiis information exercise requirements. is used to from injection to a tight control of 1 One of a day. his 4 the frequently used schedules consists of 2 injections and 3 to 4 blood samples per day. the There In this routine finger and uses a glucose amount of glucose present in the blood determine insulin dosages, dietary intake and These complex factors are only a few of the aspects of diabetes control. There are three basic insulin categories: long acting. dosage is Each category usually is made up of a combination of slower aaing faster acting regular (crystalline insulin). hour, peaks in 8 to 12 hours and insulin later is fast rapid acting, intermediate acting, and based on the effective activity time. is The slow A NPH normal insulin (Isophane) and acting insulin begins to react in gone within 20 to 24 hours. The 1 other, regular acting and starts working in about 1/2 hour and peaks from 2 to 3 hours being completely used in 4 to 6 hours (Table I). Glucose Insulin Food Exercise Figure 1 Factors Affecting Glucose Balance Table I INSULIN TYPES 1.) Rapid aaing: Takes effea - 0.5 to 1.0 hrs Most - 2.0 to 3.0 hrs effective Depleted 2.) Intermediate aaing: Takes effect - Most effeaive to 1.0 hrs 5.0 to 7.0 hrs .5 - Depleted 3.) 4.0 to 6.0 hrs - 12.0 to 16.0 hrs - Long aaing: Takes effea - Most effeaive - Depleted 1.0 to 1.5 hrs 8.0 to 12.0 hrs 20.0 to 24.0 hrs - Adapted from Travis, 1985 Dietar>' requirements include daily caloric intake which must be another imponant factor in the control of glucose levels. eat a number of smaller meals at strictly controlled, This requires the diabetic to 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 glucose level in response to the demands placed on number of other or a forces. A diabetic, it by food raise or lower the intake, stress, illness on the other hand, can not regulate the glucose levels as quickly. becau<;e insulin injected requires time to be absorbed by the body. the Nor can non-diabetic the glucose level be maintained as accurately by insulin is produced on an as-needed basis, manual means. whereas in In diabetics quantities of insulin are injected at specified times ot injections, type of insulin, diet and and "Good" control of glucose within a specified range. it is amount of exercise dependent on the number to maintain glucose levels levels in a diabetic considered is between 60-150 mg/dl (Travis, 1985). to be The type of foods (such as carbohydrates, fats and proteins) must be carefully monitored to keep the blood sugar levels consistent. This requires the diabetic to know makeup of these not only the number of calories a food item contains, but also the foods. In order for the diabetic to manage a proper diet; food exchange charts are Food exchange used in meal planning to achieve the balance required. group foods by type, relative makeup and portions. calorie charts charts give This information, along with and dietary plans gives the diabetic a basis for daily food intake requirements. Another important factor is exercise. exercise is Daily exercise in regulating the important for a amount of glucose number of important in maintaining body weight. diabetes by increasing the is is a major contributor to amount of Type 11 in the diabetes. Obesity compounds the problem of High levels of increases the body's ability to use glucose and reduces the is extremely beneficial to the diabetic. fat in the need But, at the for insulin. same Diabetes affects the body many ways, and blood stream also arteries. Exercise Therefore, time, exercise must be closely monitored to avoid an insulin reaction due to too low a glucose in is that insulin required to maintain glucose levels can contribute to atherosclerosis, the building up of deposits in the exercise blood stream One reason reasons. level. especially the circulatory system. a result poor control diabetics have a significantly higher incidence of: As coronary disease, liver damage, blindness and poor blood develop gangrenous infections Extreme cases may circulation. that often result in the amputation of limbs. Secondary infections and other disease-related complications claim the lives of 20,000 diabetics each year. problem associated with any medical condition. Finally, terminology is another Diabetes is no exception and terms, covering a many in fact requires number of terms from Terminology can become dietetic There are also diseases. and exercise terminology that need to be understood. understanding by individuals, as well as between a barrier to medical personnel and patients (Figure D. knowledge of a wide variety of medical body and a number of aspects of the 2). ONSET AND TREATMENT As with any disease, effective mellitus h>egins with proper diagnosis. puberty years; however, onset dramatically, and in many may treatment for Juvenile-Onset The occur cases the Type at Symptoms any age. may patient require stabilized The causal factors may The primary determinant of Type to produce Once a until positive diagnosis is hospitalization. made and be genetic and/or precipitated by an I diabetes often appear quite initial Frequently, in small children, the disease becomes critical before a doctor and requires hospitalization I, disease typically appears in the growth and Diabetes is is consulted the patient unknown is factor. the inability of the patient's pancreas insulin. this diagnosis is confirmed, the attending physician, usually an endocrinologist, conducts a series of tests to establish a baseline for developing a treatment regimen. The primary goal of an effective regimen is to monitor and control UBJiCaOUL mjocost arruinoNS LIVBLS CSUUN MSAOl -IIS- FOOD IXCBAN<»S I / WHWTO ICST \ / \ MIUCAL DrriD nufmoLOGY Figure 2 Decisions for Diabetics The term the level of glucose in the blood stream. control in this context refers to degree that a diabetic manages to keep his/her blood glucose level within a the The "acceptable range" specified range. is generally considered to be 60 to 180 mg/dl (Travis, 1985) however, diabetics are encouraged to strive for the to 120 mg/dl. This usually requires a strict "good control" of 80 regimen and close monitoring on behalf of the individual. The success of a treatment regimen is strongly Ac influenced by following considerations: 1. A positive and cooperative attitude toward treatment. 2. A thorough education on the fundamentals of diabetes control. 3. TTie 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 control the disease, support system and is is diabetes and wide nature of knowledge needed to maintain and an area that could vastly benefit from an automated decision the focus of this system. II. SYSTEM ANALYSIS THE NEED FOR INFORMATION A. The previous shown sections have requires a wide variety of knowledge to properly control the new when is One of the With is first amount of infomiation diagnosed. At this is and retention severely limited. is and nursing stress and This leaves the patient's learning Also the sheer volume of information needed The diabetic feels that he will that could cause serious complications or even death. dietician under great is needed or he might make a mistake overwhelms the diabetic and never learn what diabetic. provided in a short period of time, time the diabetic undergoing various stages of fear and denial. ability new finding the infomiation that can answer a specific question. is diabetic, a vast the patient The volume and maintain. and diversity of the information can quickly overwhelm the biggest problems complicated disease and that diabetes is a further increases anxiety. The first few weeks is staff are inundated with frequent also a time phone when the physician, calls for basic information (Travis, 1985). Even after the diabetic feels disease, the individual comfortable with the day-to-day maintenance of his 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: Insulin regimen and blood glucose levels. 1. a. Blood glucose level must be checked regularly. The resultant readings will and frequency of testing. If the readings affect insulin dosage, insulin types 12 normal ranges, normal insulin dosages, and exercise programs can be maintained. If not within normal range the diabetic must discover if a trend exists. indicate the glucose levels are within diet b. If the trend indicates a very low value (less than 60 ml/dl), consistent low 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, usudly 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 readings either over a period of time or repeatedly may c. be required. glucose levels above normal (greater than 150 ml/dl), 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 If the readings indicate modifications of dosages and types for Ketones. A 2. a. suitable diet plan. The food preferences — This is an extremely important Successful dietary control hinges on acceptance by the diabetic. individual's consideration. Every effort should be made accommodate food preferences within to the allowable constraints imposed by the disease. b. c. Age, sex and body weight — The dietary goal is methodology that provides the nutritional and individual based on age, sex and body weight. to develop a meal planning caloric intake for an total — Of the three major regulatory factors (diet, insulin and exercise), food and insulin have the most dramatic effect on glucose It is impossible to stabilize insulin levels if food intake fluctuates from day to day. Consistent food intake levels. Food Exchanges Charts 3. a. The Exchange Diet methodology -- This approach to diet planning divides foods into six categories on the basis of fat, protein and carbohydrate intake. Each measure is It provides standard measures for food serving sizes. All foods contained described in terms of total calories and nutrient content. 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 • Milk Exchange • Fruit • Vegetable Exchange • Starch (Bread) Exchange • Protein (Meat) Exchange • Fat Exchange b. • Exchange 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 • Fmit Exchange • Milk Exchange c. - These two components are required for proper However, they do not directly srffect glucose level in the blood. Protein and fat intake nutrition. (Travis, 1985) Exercise management 4. 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 b. Excessive exercise can cause the insulin to be absorbed too quickly causing a drastic drop in blood glucose levels and leading to hypoglycemia. increase the risk of arterial disease. These are only a few of the decisions required many of these issues can be critical. to maintain a diabetic every day; 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 14 automated system could vastly improve the quality of diabetic care over the present, mostly manual, system by providing a number of The features to aid the diabetic in the management and control of this disease. better the control of glucose in the blood stream the less likely there will be secondary complications in the future. The physician basics and some of or a health care professional and dietician teach the diabetic the 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 be discussed in general terms with the understanding that the patient will set up a personal program. months A diabetic, normally, will visit the physician for a progress review. this time. This test will preceding three months. dietician The physician conducts and dietician once every three a test of Hemoglobin Ale at give an indication of the overall blood glucose levels for the On the basis of patient progress review, the physician and may make recommendations and modifications to the treatment reinforcing cenain 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. TTie patient, may or 15 may not understand these terms or forget By the specifics. having an electronic dictionary available, more accurate information can be exchanged between the physician and the patient. also gives a reference It source for the patient to questions that might go unanswered or forgotten the at quarterly reviews. An electronic logbook with a query c^ability is needed to provide both the patient and physician the ability to quickly spot trends On required. and areas where action is a daily, weekly and/or monthly basis the patient can easUy review glucose reading, insulin dosages and changes for trends to better control and maintain The tight control. physician, in the short time available during an appointment, can what better determine is needed and give positive reinforcement where appropriate. This will give more time for personal contact and to answer specific questions, thus making A more meaningful the visit central for both the patient and doctor. meal planning capability also is needed to gather all information needed together for consistent and effective dietary control. many the different There are so diverse requirements involved in meal planning that a central meal planner could improve control immensely. dietician to make accurate it As is also provide a record for the physician and applies to likely he a diabetic learns is how to stick to the treatment to manage But there The an exercise planner. for the physician, the better the medical care. more to his physician decrease. diabetic will fine adjustments to the individual's diet. The same philosophy patient, the It The more easier and easier it is for the program. the disease he gains confidence and the calls still becomes more informed, he wants is to a requirement for information. know more and As take charge of his a life. The way to do about diet, this is There infomiation. is through information. no central location The problem is the diverse nature of the where the individual can go for infonnation food exchanges, meal plans, exercise and medical terms. the diabetic may need There various questions. also the is Even at the clinic, and the nursing staff to answer to see a physician, a dietician problem of maintaining the records needed to track glucose readings, extemal influences that affect them, insulin dosages, time and location of injections. An informed patient Some fmancial resources. a healthier patient, reducing is tfie medical burden and saving of the current systems available will be reviewed below. THE MANUAL SYSTEM B. The current system, used by most diabetics, is A a manual system. written log is maintained to record glucose readings, times of the readings and insulin dosages. A record is also needed to record daily occurrences variations, such as Ulness or stress. needed C. to A such as meals, exercise and any food exchange booklet and calorie charts are plan meals and monitor food intake. COMPUTER-BASED SYSTEMS At this systems are time there are four data management systems available to the public, these listed in Table n (Feder, 1988). A review of some of the available computer-based systems revealed two important points. this type of system, present there (i.e. is with no system Logbook with trend First, there is a move towards new systems being marketed almost monthly. that has incorporated all the features analysis. Nutrition 17 Second, at needed by the diabetic information including Food Exchange Table - 11 MANAGEMENT SYSTEMS DIABETES DATA MANUEACTURER SYSTEM Data Manager Glucometer OPTIONS Logbook LifeScan M Logbook Miles Merlin Boehringer Romeo Diva Mannheim Logbook Logbook, Limited Nutrition, Exercise Charts and terms). USDA The Electronic 1. Nutrition charts, Exercise information and a Dictionary of relevant features that are needed include: Logbook for tracking and analysis of glucose readings, insulin Patient Database contains back ground dosages, date and time of injections. medical information. Nutrition information to include exchange charts, nutrition charts and meal 2. 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 leading the diabetes management systems, the Merlin system Boehringer/Mannheim, was acquired and evaluated. TTie hand held unit connects The Accu-Chek Accu-Chek H. electronically read the automatically entered patient with an glucose when electronic 11 can be used with the glucose This level. the blood test logbook (of 18 is allows the conducted. limited storage test by to the strips to to be The system provides the glucose memory reading cq)ability of The logbook holds glucose approximately 2500 glucose readings). The dosages, date and time of injections. readings, insulin unit also allows codes to be entered to explain abnormal readings. The systems reviewed, both address the needs of a diabetic. all available to 1988). manage and graph The system includes the literature and with actual testing, did not in The Merlin Diabetes Data Management System the data, at additional cost, (Bochringer a patch cord to upload the data in the Merlin unit to a personal computer and the associated software for either an The software allows maintained. week patient with records limited CGA monitor. background information to be and mean values. and chans can be displayed on the terminal or sent disadvantages are listed in Table menu the exception of the on nutrition or exercise. to a printer. All of the graphs The advantages and III. Diva system, available for glucose reading storage. most or Various graphs and trend analysis functions are available through as well as providing standard deviation With EGA Types of trend analysis include graphs of glucose readings by meal, day seleaions. of is Mannheim, all of the other units have limited memory Also only the Diva system had any information The Diva system was the most comprehensive, but was the 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 comprehensive diet planning and Additionally, none of the systems allowed for ad hoc query of the database. comprehensive system was needed to control. A more provide the diabetic with the necessary tools for comprehensive control and management. 19 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 Need to Lack of Difficult to obtain Remember Exception Codes Flexibility 20 III. DEVELOPMENT TOOLS METHODOLOGY A. A review of the systems development and the literature natiire of this problem (semi-structured decisions) indicated that a Decision support System (DSS) approach was best suited to the task at hand. approach was to (Representations, Furthermore, it was concluded that the best design develop the Decision Support System (DSS) utilizing the Operations, Memory Aids and Control ROMC 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) The major and the project's constraints. constraints include: Limited programming expertise of the builders. 1. The requirement to provide a "user friendly" woridng prototype within six months. This was based on the premise that many of the users will have 2. limited computer experience. The requirement 3. to deliver a system that would provide a useful decision The system had to appeal to support system and enhance user productivity. physicians, dieticians and diabetic users. The requirement to identify and apply advanced complicated project and show proof of concept. 4. L ROMC The process that to solve a and Prototyping ROMC is technology approach is suitable for this type of project. characterized by prototyping. ROMC is an iterative gives a builder the flexibility to design a Decision Support System without needing to 21 It first identify all of the user's decision-making processes. Sprague and Carlson (1982) point to other advantages that include: DSS Help 1. builders and users to segment the decision problem and identify the relevant intelligence, decision and choice of operations. Allow 2. 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, iteration. This process the least expense, early in the maximum promotes development process and provides 2. at development Together, the builder and user can refine the model with each successive process. maximum user participation throughout flexibility for incorporating the changes. 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 p)ersonnel and diabetics), a literature review and interviews with commercial software developers, proposed system was feasible, 2. 3. if new it was concluded that the software technology was ^Jplied. 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. ROMC — Using this technique and conventions, an 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. Prototype development initial 22 ROMC AND SYSTEM ANALYSIS B. ROMC provides a process independent methodology for defining, analyzing, designing and constructing decision support systems. this feature as being among the Sprague and Carlson (1982) view most important characteristics of the ROMC qjproach. Process independence allows the builder to analyze and establish the user's requirements with no prior commitment to the user(s) decision making when extremely significant describe their decision style. This is considering the fact that most users cannot adequately making process. Sprague and Carlson note that users and chans) when formulating a decision. most often use visual cues Based on this knowledge, (pictures, graphs ROMC provides the p>erfect vehicle for analyzing user requirements for decision support systems. Applying these conventions system requirements listed in to the Diabetes Support Systems produced the general Table IV. SYSTEM RECOMMENDATIONS AND DESIGN CONSIDERATIONS C. 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 2. 3. Automate the collection and storage of glucose readings and insulin dosages. Provide graphical displays of blood glucose levels for trend analysis, exception reponing and diagnostic control. Provide the ability to display/print food exchange planning. 23 charts as an aid for meal This will allow the user to Provide an automated menu planning function. select foods from a food exchange database and input those values directiy into 4. ROMC Table IV Systems Requirements Representations 1. 2. An electronic logbook for storing insulin doses/glucose readings. Trend analysis bar/scatter graphs depicting glucose levels (screen displays and printed graphs). 3. Food exchange 4. A 5. Printed daily menus. menu charts for 6. Food composition 7. A 8. menu planning (screen displays and printed reports) planning template (screen display design workspace). charts for reference (screen display and printed reports). medical reference dictionary (screen display) Exercise activity charts depicting caloric expenditure (screen display and printed report). Operations The following print functions: view, edit, data entry, graph, delete, insert, save, query, 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 nutrient, serving size be stored and/or printed. The menus should provide and exchange mlbnnation. calorie, 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. SOFTWARE SELECTION D. 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 scope feasibility study, the of the project was discussed with the director of software development for Boehringer Mannheim (Merlin Diabetes Monitoring National Institute of Health. Dr. System) Rodbard and and Dr. David Rodbard his colleagues pioneers in the development of software for monitoring diabetes. stated that this project However, development time. Rodbard used was probably third it was to identify and A 2. A DBMS, 3. An Both gentlemen should be noted that Boehringer Mannheim and Dr. generation programming languages to develop their respective it was Based on these interviews, and the decided that the only feasible way utilize a state-of-the-art fourth generation software features considered essential to 1. the not possible in terms of budget, personnel and systems (compiled Basic and Pascal respectively). project's constraints, at were among the early development were: microcomputer based product. preferably relational. application generator. 25 to accomplish the task software package. The A 4. 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. earlier version, Paradox In addition to meeting the selection criteria, Paradox 3.0 2.0. categorically out-performed This product was a significant update of an all the 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 It is is a microcomputer-based relational database DOS compatible with both the and OS2 management system. operating systems. It supports stand- alone, as well as network operations. The software package 3.0 DBMS and the consists of primarily Personal Programmer. two individual programs, Paradox 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 a is Paradox has driven system designed for use by individuals No programming levels of experience. since menu its own application expertise is Paradox objects A Paradox Program. However, applications can be Programming Toolkit. (tables, forms, reports flexible all required to develop applications generator. significandy enhanced through the use of Paradox's, Ascii based. Pal Language and the Data Entry at and graphs) are constructed within the form and report generator provide the means to design customized produas. Both suppon linked/unlinked and single/multi-table presentations. Paradox offers the flexibility of performing data entry, update, modification and output funaions via custom forms and reports or directly to/from the relations themselves. The Paradox Personal Programmer provides the means style menus, and allows the user DBMS, view, to a variety of edit, procedures). menu to generate to connect objeas, previously constructed in functions. The available menu Paradox Paradox selection actions include: repon, dataentry, query, graph, print and scripts play (executes custom 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 the tables and create customized views of individual DBMS. However, for stand-alone from or multiple tables within the applications, queries must be predefined. This requires close user/builder communication to ensure the useful views are constructed. Additionally, the fields in QBE feature allows the user to select and sort data in individual ascending or descending order. 27 In summary, Paradox 3.0 generation DBMS is limitations discussed in chapter five. was finalized an extremely flexible and comprehensive fourth and software development and constmction was Once the started. 28 tool. However, program was it does have some selected, the design phase SYSTEM DESIGN rv. INTRODUCTION A. The Diabetes Support System was designed to enable users with limited experience the freedom to use the system with the It minimum amount computer of preparation. provides physician, medical staff personnel and diabetic users with a decision support system that features the following integrated software applications: 1. The 2. A application provides an electronic logbook for recording dosages/glucose readings, as well as several trend analysis functions. patient record selection that allows the medical staff to access patient records and specific medical background and 3. A insulin diet information. FDA food charts and can be accessed for planning menus and or nutrition application that contains a database containing diabetic food exchange charts that determining the nutritional content carbohydrates, (fats, proteins, etc.), as well as calculating caloric content. 4. An exercise expenditures application for various containing aerobic a database exercise for determining caloric The caloric based. activities exp)enditures are based on age, weight and sex. B. DESIGN OVERVIEW The Diabetes Support System suppon system. It It was designed decisions from the three insulin/glucose was designed will provide information to stmctured in support of physicians, dieticians controlling diabetes. application diagnostic as a specific decision and semi-structured queries and diabetics, for the purpose of monitoring and as a comprehensive system major diabetes regulatory information into 29 a factors, single that could consolidate exercise, source, nutrition interactive and software application. The system was constructed computer running DOS 3.1 or higher. megabyte or a hard disk drive for use 640K of on any RAM IBM compatible personal and secondary storage of 1 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 For the purpose of discussion in this paper, the application is entity. described and examined as one program. SYSTEM COMPONENTS C. The Diabetes Support System consists of the three characteristic identify a decision support system: a database, model base and an components that 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. relations serve as validity-checking functions. 1. Patient Records diet 2. 3. The primary and medical mechanisms In addition, several auxiliary that are activated through table lookup relations consist of: — containing individual patient records (personal information, history). Logbook ~ an electronic logbook containing individual patient glucose readings, insulin dosages, dates and remarks. The data for the glucose trend analysis graphs are extracted form this table. Foodex — This table contains food composition records for the diabetic food exchanges. 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. 4. — 5. Mealrecs 6. Dictionary 7. Exercise 8. Profiles ~ - menu records. a reference diaionary that contains useful medical terminology. information on caloric expenditures for specific hKxiy weights and exercise aaivities, used as a reference source. - contains the date the Diabetes Suppon Systems 's model base supfwn glucose trend graphics internal Access relation. Ad is hoc to the -- when models models were constructed using Paradox's and are supponed by data contained model base can be accomplished in in the Logbook one of two ways: Ad hoc trend analysis operating direcdy under the supervision of the Paradox DBMS. analysis selections 3. data from the consists of graphical display using Paradox's query-by-example feature. onlv available 3.0 Tlie analysis. generator, Predefined queries that are embedded 2. profile. menu was prepared and lookup The Model Base 2. 1. menu contains information on a patient's individual Mcnudate - contains Foodex relation. 9. that contains patient The Interacti\e Lser Dialogue The application provides an This menu Personal Programmer. seleaions are available structure interactive The menu displays and on-line help functions conventions. in the stand-alone application under trend . user dialogue through strucnire uses each Paradox was designed and construaed using Help screen displays were at menu installed level to guide the user. 31 menu style driven menu the Paradox by the builders. Help The menu structure controls the access to application's database base, and guides the user through the system. The Appendix variety of functions. menu associated also allows the user to select a menu contains the complete hierarchy along with selections. REPRESENTATIONS, OPERATIONS, D. It and model MEMORY AIDS AND CONTROL MECHANISMS As previously stated, the Decision Support System. functions using Menu ROMC ROMC technique was silled to design the Diabetes This section examines the application's organization and The discussion conventions. will focus on the systems Main and two of the more complex modules: Trend Analysis (accessed structure 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 for clarification only. is allow the reader to identify where the selection first digit refers to the clarification purposes. present, is the 2.3.1. the first menu number which the selection third on menu level is main menu select, The second selection digit reached. and the which is are 32 hierarchy. will The left to right for level and the third digit, if An example would be selection (Patient Records) through digit (3) indicates the selection is at the third (1) digit refers to the first that level. menu numbered from menu left to right. Main Menu The second The convention used located in the the numbered from (2) refers to the is menu item (Update Patient) The Main Menu 1. The main menu provides access to all of the Diabetes Support System's selections and associated fomis, reports, graphs and functions. select one of 1.1 menu six selections: 2.1 Patient Records 3.1 Reports 4.1 Nutrition/Exercise 5.1 Dictionary Help 7.1 Leave a. Representations b. Operations -- allows the user to (Figure 3) Logbook Electronic 6.1 It menu -- Screen presentation of Main Menu Each menu item provides access to selections. the second-level menu selection items. c. d. Memory Aids - Menu highlighted. selection is Control Mechanisms selection descriptions for each item stppcai On-line help - The menu is when the also available. selections and Leave selection (exits program). LI 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 presentation of Main 33 Menu level menu selections. a o CO a :& d o CO s 34 Electronic Logbook Update Logbook Figure 4 Trend Analysis Electronic Logbook Level Two 35 Help Operations b. ~ Each menu item provides access the to second-level menu selection items. c. Memory Aids — Menu selection is highlighted. d. Control selection descriptions for each item appear On-line help Mechanisms - The menu is when the also available. Leave and selections selection (exits program). 1.2.2 Trend Analysis Second-level a. menu Representations - — Operations c. Memory Aids ~ A Control Mechanisms A menu second-level The user trend analysis. is By Day 1.3.2 By Meal 1.3.3 Help is selections. selection items. when appears selection is available. — The ENTER key menu selects menu selection. selection that allows the user to Representations — — Operations c. Memory Aids — highlighted. that access the glucose prompts the user for the patient's menu last and first selections that support third-level selections include: (Figure 5) b. d. menu description then provided access to the third-level The 1.3.1 a. menu Trend Analysis logbook relation through a query name. selection On-line help selection highlighted. 1.2.2 access third-level trend analysis selections. tfiat Controls access to three third-level b. d. selections Screen presentation of second-level Screen presentation of second-level menu Controls access to three third-level A menu selection On-line help selection Control Mechanisms menu description selections. selection items. appears when is available. ~ The ENTER key 36 selects menu selection. selection is Trend Analysis By Day Figure 5 By Meal Help Electronic Logbook Level Three 37 1.3.1 By Day Third-level menu selection that gives access to fourth-level menu selections. (Figure 6) 1.4.1 3 Day Trend 1.4.2 7 Day trend Day Trend 1.4.3 14 1.4.4 Help a. Representations b. Operations c. ~ Screen presentation of third-level is description selections. selection items. appears when selection is available. — The ENTER key Control Mechanisms 1.4.1 selection On-line help selection menu menu Controls access to four fourth-level Memory Aids - A menu highlighted. d. - selects menu selection. Three Day Trend This selection will result for trend analysis. When in a selected, the graph of the last three logbook relation day's glucose readings accessed and the is 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 These night blood glucose tests. constmcted displaying a title indicating the "Glucose Logbook 3 Day Trend". This axis is The X-axis are placed in an answer number of days The Y-axis table. A graph is and then for the graph; in this case, displays the glucose range in rnTdl. automatically scaled based on the highest value present in the sample. displays the dates. glucose readings by meal. A A key is blank screen provided that is is used to differentiate the presented to the user until the graph displayed, hiding the selection and background steps. (Figure 7) 38 is Figure 6 Electronic Logbook Level Four (Jlurnsr Sngbonk 3 Bay Qlmti DfTW Night 06/23/89 06/21/89 06/22/89 Dote Figure 7 Three Day Trend Analysis 40 Nutrition/Exercise 4.1 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 b. Operations c. Memor>- Aids d. Control 4.2.1 A -- - Screen presentation of a Main Selects menu A menu -- Menu selection items. item. selection description and on-line help Mechanisms - The ENTER key activates the menu is provided. selection. Nutrition 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 4.3.4 Help Food Values - Screen presentation of third-level a. Representations b. Operations c. Memory Aids - A menu - Seleas menu menu seleaion item. selection description and on-line help. 41 items. Nutrition/Exercise Nutrition Figure 8 Exercise Reports Help Nutrition/Exercise Level Two 42 Leave Nutrition Food Exchanges Meal USDA Planning Food Help Values Figure 9 Nutrition/Exercise Level Three 43 d. Control Mechanisms ~ The ENTER key key returns the user to the 4.3.2 A menu activates the menu The ESC selection. Main Menu. Meal Planning menu third-level selection item that provides access to four fourth-level selection items. (Figure 10) 4.4.4 Menu Design 4.4.5 View/Edit Menus 4.4.6 Delete 4.4.7 Help Menus — Representations b. Operations c. Memory Aids - d. Control Mechanisms ~ The ENTER key key returns the user to the 4.4.4 A — menu Selects Menu menu Screen presentation of fourth-level a. A menu selection items. item. selection description and on-line help. selection. The ESC selection item that allows the user to access the MenuDate second-menu activates the menu level. Design fourth-level menu and MealRecs relations for the purpose of designing and storing personalized daily menus. Representations a. - A multi-table/multi-page screen presentation form that contains the following: 1. 2. 3. A master form that is used to enter date and day to the One embedded form used to into the MenuDate relation. One embedded form used MenuDate enter a patient's personal data and to enter relation. 44 relation. menu profile food exchange data into the MealRecs Meal Planning Menu Edit Delete Design Menus Menus Figure 10 Help Nutrition/Exercise Level Four 45 — The primary function of this module is data entry. This accomplished through the multi-table form. Data entry operations include: Operations b. 1. A table lookup function used MenuDate 2. A table This relation. is Number) (Social Security from die Profile to enter data activated when die cursor is is relation into the SSN placed on the field. lookup function used to enter data from the Foodex relation into the relation. This is activated when the cursor is placed on the Food MealRecs 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 4. A field. table lookup function used to select and enter the value for the This copies 5. c. the Codes Meal relation field. into the field. Keyboard entry to the "Date" Memory Aids - A user to select the F2 key CTRL-U last to Meal value from selected the MealRecs Meal undo and "Units" screen message located fields. the top of the form prompts the complete the data entry process, ESC to cancel and to change. It at also includes specific instructions for entering data. Control Mechanisms d. — The master form has the following embedded control mechanisms: 1. The F2 key completes the data entry process and returns the user to the main menu. 2. The F3 and F4 keys allow form to another, Up and the user to Down move the cursor from one embedded This allows the user to activate respectively. the data entry 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 Fl and F2 Keys allow the user to activate table lookup functions. This 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 is function. 5. The ESC key allows the user to cancel the editing session. 46 Validity checking 6. Embedded a. is validity provided check in two ways: settings. Auxiliary table lookup functions described above. b. The master form (MenuDate) enforces 7. referential integrity by providing the following links: A a. A b. many from the MenuDate relation to the MealRecs on the key fields SSN and Date. relation. one to many link from the Menudate relation to the Profiles tables are linked on the Key field SSN. relation. one The to link relations are linked The 8. The PgUp/PgDn keys allow 9. Pressing CTRL-U The fomis and will undo move from one page the user to reports have been designed to aid the user in the input of data by having value range checks, lookup tables and default value ranges will notify the user that a value entered with a tone and will automatically go into edit is entered. Lookup F2 key The user is needed until a value that is within to current date in entered from the computer's clock by displaying a data when in. i.e. The user is required a date field, and the the cursor is moved from field. will discuss the conclusions of the entire process. 47 range Default entries are provided to be keyed only to place the cursor into the field that has this capability, The next chapter The value highlights the desired selection and to enter the data into the form. reduce the amount of information that entries. not in the range of possible values is mode tables are provided to aid in the entry of data table with all the possible selections. presses the to another. the last changes. the V. DISCUSSION AND CONCLUSIONS USES OF THE DIABETES SUPPORT SYSTEM A. The Diabetes Support System has professionals and the diabetic. central location for the vast a number of advantages to offer The major advantage of the system boA is it the health provides a 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. amount of the information needed The system could provided. is A significant 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 ready to be on his own. computer experience. The menu With use of structure this is when he is simple and can be used with limited system the diabetic can start taking charge of his life sooner. The Patient Data section can be used information on the patient to refresh his would be It beneficial in large or high will provide essential information The Electronic memory volume improve the "personal" touch. diet needed for each months of glucose readings 48 visit. the physician and patient to monitor the with glucose monitoring and insulin manipulation. printouts and graphs of the three This prior to seeing the patient. clinics to on medical history and Logbook can be used hy both patient's progress by the physician to provide background By having available, the physician can easily identify trends without the need to leaf through pages of a standard hand- wntten logbook. The patient make needed adjustments is able to use these features to monitor daily trends and 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 The control has not been good. if Nutrition section can also be used by the dietician and the patient for meal planning and discussions about food exchanges and caloric intake. the patient has the ability to plan and printout daily nutrition requirements. This will essential element in diabetes control. menus Witfi this system to aid in calorie intake and allow a better exchange of infomiation for an Menus, planned by the and suggestions or alterations can be made The Dictionary seaion, although of patient, can be reviewed easily. 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 With the market arc very structured and allow only certain information to be input. use of the remarks sections the physician, dietician or the patient has an area where specific comments and amplifying information can be for the patient to also has remember codes more information to explain various stored. This eliminates the need glucose readings. The physician available about the patient's medical history; such as other diseases and types of medication the patient 49 is taking to avoid confliaing treatments. system If the queries. is run under Paradox the query-by -ex ample feature is available for ad hoc This will allow for almost unlimited flexibility in information access and Query Language (SQL) The system is may be This could be used in clinical research. also has the capability of being used as The system can be used enhanced when Structured further added by the end of the year. as a total Diabetes Support Nutrition/Exercise section can be used separately. two stand-alone System with all its applications. features or the This will allow the dietician to maintain only the information pertaining to diet on another computer or only access the needed. portion This feature will give Type a stand-alone a diabetic 11 Nutrition/Exercise section that would be of most use to him. B. PARADOX 3.0 PROBLEM AREAS AND ADVANTAGES The Advantages 1. The advantages of Paradox 3.0 far outweighed previously stated in chapter HI, the Paradox system the disadvantages. was chosen because it As 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 fourth generation language provides the user with the ability to develop a complex management system without Paradox large facilitated prototyping (4GL) is that it and sophisticated data amounts of programming experience. The power of by aUowing 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 of the PAL week learning phase. programming language. This was further enhanced by the use This was used to write code to perform specific 50 functions and add enhancements to the final product. flexibility and allowed a more comprehensive application Another advantage of Paradox 3.0 developed The combination added it is greater be developed. to once a system application has been that can be run as a stand-alone system, with the soon-to-bc-relcased Run- Time program. This will allow the system to be run without the underlying Paradox program. Problem Areas 2. Several problems were identified with the use of Paradox 3.0. initial learning curve that As with product. to overcome. A all is encountered new and learning curve. to The third the first, DBMS, is that the Personal Although related and is a large learning curve similar, Paradox actually consists Programmer and the PAL each necessitates a separate PAL programming language was structured somewhat like Pascal command abbreviations that were not well-documented. contained a number of A the This was expected to some degree. second problem, related programming Language. it was dealing with any unfamiliar software sophisticated software, there primarily of three main programs, the but when First problem that was encountered was documentation and reference manuals. the quality of the vendors' support Although comprehensive in nature, they were poorly organized and lacked a complete glossary of error messages. This increased the difficulty of debugging. also. A library of sample At the time development was PAL started, available. 51 applications would be most welcome only information from Borland was The database management system was easy number of features that took time to master. The database tables, fomis and reports. query-by-example added great the menu structure to The flexibility. In considering the to build the excellent; the to build There were a number of problems summary, some of the problems were due and was used errors developing after This proved to be due, in part, Borland company has been unable to correct. version shortly after a major revision. major had a large program were The major problem involved that the use, but The personal programmer was used repeatedly recompiling the code after frequent changes. problem DBMS capabilities of the and generate the basic code. encountered with this code. to an existing leam and and size to the use of a newly released The problems encoimtered, however, were not complexity of the Paradox were system insignificant. THE DIABETES SUPPORT SYSTEM CONCLUSIONS C. The Diabetes Support System (DSS) proved first envisioned, as is typical of to be a much most systems development larger project than projects. comprehensive application was developed in 4 months on a part-time With the major backlogs of software awaiting development a 4GL will allow the users to develop some programming department to address The Diabetes Support System, system can be developed in shows that problems However, a basis. most organizations, systems themselves and free the in other areas. as proof of concept, minimum in shows that a comprehensive time using fourth generation technology. decision support can be applied to diabetes control enabling better treatment and comprehensive care. 52 was It also and maintenance, The Veterans Administration and in A need of automation. management the military medical systems are overtaxed and Diabetes Support System that can be used as a teaching aid much and as a staff. This application allows for easy maintenance of patient records as well as tool will reduce of the administrative work load on the meal planning and exercise programs. specific trend analysis, By having much of the data needed to manage diabetes in one location, valuable time can be saved for critical needs. In high volume with each patient. By clinics, the in small clinics. at least give the impression of personal involvement This will reinforce the patient's feeling that someone cares how they are doing, encouraging D. THE FUTURE him to stay on the strict regime. of the repons and graphs were reviewed by endocrinologists and some Some enhancements were suggested. mean and physician docs not have the time to spend being able to quickly access the patient's history and any personal data, the physician can one sees more standard deviations. graph be added to the selection. This entailed the addition of It was also suggested that a These features could most statistical data, 30 day glucose such as scatter likely be incorporated into the system without major changes. The Diabetes Support System is the next step. results system. point where a comprehensive testing phase in a clinical situation or a endocrinologist's office. system to be evaluated under normal operating conditions. from the beta At at a After corrective maintenance for any errors has been finished, the system should be beta tested will allow the is testing, the final This With the enhancements or changes can be added to the that time the final versions of the 53 documentation can be completed. APPENDIX USERS MANUAL A. PROGRAM OVERVIEW The Diabetes Support System (DSS) the diabetic to better manage to maintain patient records home, the system, in the strategy is diabetes. By is able to use the and as an teaching aid for diabetics. to help with to allow the user a unified yet simple to use. designed to enable both the physician and is The physician having all The DDS diabetic can use The DSS blood sugar control and monitoring. system that is both flexible the information located in system in its breadth and one place, the user can A easUy obtain the needed information to maintain a proper glucose balance. menu- type system was used to reduce the required learning time. The menu numbering is for clarification only. the reader to identify where the selection is number main menu which refers to the clarification purposes. present, is the 2.3.1, the first menu number which the selection third menu Patient) on level is select, The second number selection and the is are the numbered from (2) refers to the reached. (1) number 54 level left to right. Main Menu that level. menu will allow The hierarchy. numbered from menu The second number third The convention used located in the and the An left to third first right for number, if example would be selection (Patient Records) through (3) indicates the selection is at the refers to the fu^t menu item (Update Main Menu The Main Menu a. Electronic The includes 7 selections consisting of: (Figure Al) Logbook 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 b. The Patient Records selection contains a database containing the patient's background information c. d. to include: address, medical history and diet. Reports The Report Logbook, blood glucose levels within desired levels. Patient Records section provides copies of: Patient Records, Patient Glucose a Patient Listing ref)ort, and Trend Analysis graphs to the printer. Nutrition/Exercise This selection provides two sub-sections, one for food related information and the other for exercise. foods The nutrition section contains a and diabetic food exchanges. It comprehensive database of allows the user to buUd 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 readily accessible list of diabetic and medical terms plus defmitions for the user to answer frequently asked questions. 55 o o o CO tn a a> a o < 2 B Help /. At each menu level there Help menu a is to provide on-line help to the user. Leave g. The DOS leave selection is used to quit the DSS program and return to the level. CONTROL MECHANISMS B. 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. 1. 2. ENTER ESC -- -- used to activate returns you menu selections or functions. to the previous menu, with one exception. When performing ESC key can be used to cancel those an edit or data entry function, the functions. 3. TAB - 4. TTie Right/Left 5. Tlie 6. used to activate a table lookup function. Tliis is accomplished by placmg the cursor on the designated field and pressing the Fl key. This will Move the cursor to the record that place the lookup table on the screen. Then Press the F2 key; this will contains the data that you wish to copy. complete the function. 7. used to move the cursor horizontally Arrow keys — same Up/Dn Arrow keys F1/F2 -- used to as the move from Tab field to field. key. the cursor up or down. — F2 only — used to complete Main Menu. editing or data entry function. to the 57 This will return you F3/F4 keys 8. — move used to the cursor from one embedded form to another within a multi-table form. F9 ~ used 9. 10. Pressing to activate the editing CTRL-U will undo mode. the last changes that were made during an edit or data entry session. Pressing 1 1 2. CTRL-BREAK Selecting Menu To choose a will stop a report from being printed. Items menu selection, either — type the - use the arrow keys to highlight the selection and press the To first letter of the selection, or cancel the selection or move to the next higher menu ENTER level press the key. ESC key. C. MENU SELECTION DETAILS 1. Electronic The is Logbook Menu Structure Electronic Logbook is the master record of glucose readings. The logbook indexed on the patient's social security number (SSN) and an individual's accessed by the patient's name. The second level The glucose readings are further indexed by file is date. 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. 1.2.1 Update Logbook 1.2.2 Trend Analysis 1.2.3 Help The sub-menu 58 consists of: (Figure A2) Electronic Logbook Update Logbook Figure A2 Trend Analysis Electronic Logbook Level Two 59 Help Level a. Two Structure Update Logbook 1.2.1 This selection allows the user to select an individual's glucose logbook. The user is queried to enter the patient's The user name. patient's will now last name and is i.e. to and date of In last visit. The insulin dosages are grouped by breakfast, lunch dinner, dinner and night time with the types and amounts of insulin (regular or NPH). time of day visit a table, in tabular form, consisting of the date, insulin dosages, glucose readings and a remarics section. time of day first see a multi-view table consisting, in the top half, the name, Social Security Number, date of next the bottom half of the screen then for the patient's in the same manner The glucose readings as the insulin dosages. A down by are also broken remarks section provided is 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 accomplished by either the arrow keys or more easily with the logbook Down is keyed on the date and are listed in order of date. keys are used to move vertically through the field to ENTER key. The Page Up logbook records field is The and Page to find, update or review a specific date. (Figure A3) 1.2.2 Trend Analysis The Trend Analysis the apjpropriate records. 1.3.1 By Day 1.3.2 By Meal selection first queries for the patient's name This leads to a third level sub-menu: (Figure A4) 60 to select o o o CO 61 Trend Analysis By Day Figure A4 By Meal Help Electronic Logbook Level Three 62 Help 1.3.3 Level Three Structure b. By Day 1.3.1 This selection allows the user to select trend analysis of a previously selected patient glucose logbook. days of glucose readings. The The day trend will be based on a selected selection leads to a fourth level number of sub-menu A5) consisting of: (Figure 1.4.1 3 Day Trend 1.4.2 7 Day Trend 1.4.3 14 Day Trend Help 1.4.4 c. Level Four Structure 3 1.4.1 Day Trend This selection will present, from the patient's logbook, the glucose readings in a graphic form. 7 1.4.2 in a 1.4.3 This will allow trend analysis. (Figure A6) 14 graphic form. last days glucose readings Day Trend in a graphic form. TTiis will allow trend analysis. Help The Help seven days This will allow trend analysis. This selection will present from the patient's logbook, the 1.4.4 days Day Trend This selection will present from the patient's logbook, the glucose readings last three selection provide on-line help to the user. 63 last fourteen Figure A5 Electronic Logbook Level Four 64 (SHurosf ii[0gb00k 3 ioy (Ermft ftodtfost Uftti V//////A Dinrer 08/21/89 08/19/89 08/20/89 Dote Figure A6 Three Day Trend Analysis 65 Level Three Structure d. 1.3.2 By Meal This selection allows the user to select trend analysis of a previously selected patient glucose logbook. number of days of glucose menu consisting of: (Figure 1.4.1 3 Day Breakfast 1.4.2 7 Day Breakfast Day 1.4.3 14 1.4.4 Help e. The readings. trend will be based The meal on a selected meal for a selection leads to a fourth level sub- A7) Breakfast Level Four Structure 1.4.1 3 Day Breakfast (Figure A8) This selection will present the user with a gr^h 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 breakfast glucose readings for trend analysis. 1.4.4 Help The Help selection provide on-line help to the user. 66 last fourteen days By Meal 3 Day Breakfast Figure A7 7 Daj 14 Day Breakfast Help Breakfast Electronic Logbook Level Four 67 (Jlurosp logbook 3 Bay Smtft Qmi^ost. 200 1 150 1 100 50 i II OB/21 /SB QB/19/89 06/20/89 Date Figure A8 Three Day Breakfast 68 Other meal selections will be added for lunch, dinner and night when the application 2. is readied for beta testing. Patient Records The Menu Patient Records selection allows the user to view, update, add or delete patient records. Moving between the F4 key as in the Electronic of; (Figure A9) 2.2.1 Upxlate Records 2.2.2 Delete Records 2.2.3 Patient Listing 2.2.4 Help a. Structure Level 2.2.1 Two the record sub-sections can be accomplished Logbook section. The second level sub-menu consists Structure Update Records This selection allows the user to view, update and enter When the user selects this the patient record to select. menu item a query will ask for the last and The user containing the patient's background. sections: by using background information, new records. first name of will then be presented with a multi-record The Patient Records record medical history and diet is form divided into three information. background information consists of the patient's name, address, telephone number, and next visit. 69 The last Patient Records Update Records Figure A9 Delete Records Patient listing Patient Records Level Two 70 Help Medical background. diseases for History section holds a summary of which the individual may be under treatment. information on medications to avoid conflicting treatments. the medical the medical patient's This has valuable inlonnation about the patient's diabetes and other section is the remarks It also contains critical Another essential part of This allows the physician to add section. information pertinent to this specific patient, adding flexibility to the entire system. The last section holds information on patient's about caloric intake and diet restrictions. diet, with important details Again, a remarks section available to add is patient specific flexibility. This selection also allows the user to add a patient to the database. The user user will be presented with a blank multi-record form. background data for a new saving data or key is used. Undo what patient. The user can has been entered. enter data, To move will then ESC in the fill to quit without fi-om field to field the After the data has been entered the user press F2 to save the to the database. The ENTER new For a description of the form see Individual Record below. record (Figure AlO) 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 desired record. The name must be last and the first name of capitalized in order to find the correct record. the Patient Data Naie: Data SSN: 12:.-45-675E Aqe; Address: 12345-5000 Tell: I-Jar,-B' Visit: 1-Apr-S9 Dietary Ht: Wt: o2 115 Last Updated: fiqe ct Ideal State: Last Visit: Ne.-t 35 114 Osk St. four Town City: Zio: , heflical Saiple 2: Rec. «: Diatetes On-set: Range: to 120 80 HvpoglyceiiC Below: 40 12;-456 Hb (405. History 23-nay-8'' 15". 4* ci. lbs. 52.15* kg, 9.c Date: 1-Fefc-B9 Previous; 10.1 Date: l-Dec-6^ T,?? Insulin 1: Hufulin NPH Dailv Calorie Intake:' 1500 Choiesteroi LDL: Lo* sodiui r.'N: 35 ) HDL: 1'7 Low Fat >/N: Reaarks: Figure AlO il/dl Last: file Intonation In. le iLdl Patient Record After the name has been The first name. number Medical History and a Diet Information. Patient Records section contains the patient's name: last Next is the Social Security for each patient. Code can be entered This is this is the key or as the and name, and is Zip+4 number. The Last for tracking quarterly clinic visits. an information field followed by the patient's age and address. how allows the physician to determine is Number; number as a 5 digit Next Visit are dates used birthday field This fonm entered a master patient data fomi will appear. will consist of three sections: a Patient data. field. recent the information a unique The Zip Visit and The Last Updated field for each patient. The is 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. TTie background of the patient has Medical patient. History The first entry had diabetes. This information is information on the normal glucose range and last two hemoglobin Ale readings amount of are control over the last 6 months. case an insulin reaction occurs. the medical Age of Onset, to indicate how long the information important in order to determine the types is of medical problems that might exist or develop. Tlie on comprises section The range and hypoglycemic provide when to expect hypoglycemic reactions. provided to remind the physician the The types of insulin used is provided in 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. 73 The diet section contains a daily caloric intake restrictive diet. is The summary of the patient's diet regimen. provided along with whether the patient it. fat or sodium broken into both high and low density patient's cholesterol is cholesterol, so the physician can monitor on a is The 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 patient's record for deletion. last and name first to select the This selection must be used with caution because the records are permanently lost and can not be recovered. 2.2.3 Patient Listing Listing provides Patient 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 3. Help Help provides on-line help to the user. Reports The Reports patient records section provides a means of obtaining a printed copy of and the glucose logbook. containing: (Figure All) 3.2.1 Patient Records 3.2.2 Patient Listing 3.2.3 Patient 3.2.4 Trend Analysis Logbook 74 It consists of a second level the sub-menu Reports Patient Patient Patient Trend Records Listing Logbook Analysis Figure All Reports Level Two 75 Help Help 3.2.5 Two Level a. Structure Patient Records 3.2.1 The user wiU be prompted A the proper record. for the patient's last and first name It will A12) consist of the information described in the Patient Records section. (Figure Patient Listing 3.2.2 This will provide a listing of all the patients in the database. of the patient's Social Security Number, name, age, (Figure to select printout of the patient record will be sent to the printer. and next last visit consists It clinic visit. A13) Patient 3.2.3 The user the proper records. 3.2.4 and by meal. b. will be queried for the patient's last The patient's glucose and logbook will be sent first name to select to the printer. Trend Analysis The user glucose logbook. Logbook is prompted for the patient's name to select the correct patient This selection leads to a sub-menu containing the selections by day These in turn lead to sub-menus in order to print the various trend Level Three Structure Trend Analysis has a 3.3.1 By Day 3.3.2 By Meal 3.3.4 Help level three 76 menu consisting of: (Figure 14) o a CO a. < u CO CO a; u 78 Trend Analysis By Day Figure A14 By Meal Help Reports Level Three 79 The By Day 3.4.1 3 Day Trend 3.4.2 7 Day Trend 3.4.3 14 selection consists of a menu consisting of: (Figure 15) Day Trend Help 3.4.4 c. Level Four Structure 3.4.1 Day Trend 3 This selection will print a report of the patient's logbook, the 3.4.2 7 days glucose readings in a graphic 14 Day Trend form. This selection will print a report of the patient's logbook, the seven last fourteen This will allow trend analysis. Help The Help 3.3.2 last This will allow trend analysis. days glucose readings in a graphic form. 3.4.4 A 16) Day Trend This selection will print a report of the patient's logbook, the 3.4.3 last three This will allow trend analysis. (Figure days' glucose readings in a graphic form. selection provides on-line help to the user. By Meal (Figure A 17) This selection will allow the user to select trend analysis of a previously selected patient glucose logbook. number of days of glucose menu The readings. trend will be based The meal consisting of: 80 on a selected meal for a selection leads to a fourth level sub- Figure A15 Reports Level Four 81 (SlurnsF lEngbnok 3 Bay Qlmxi Lurh V/////A Dinner V//////A Night Oe/23/re OB/21/89 CB/22/a9 Dote Figure A16 Three Day Trend Analysis 82 By Meal 3 Day Breakfast Figure A17 7 Day 14 Breakfast Day Help Breakfast Reports Level Four 83 3 Day Breakfast 1.4.2 7 Day Breakfast 1.4.3 14 1.4.1 Day Breakfast Help 1.4.4 d. Level Four Structure 1.4.1 3 Day Breakfast This selection will present the user with a grj^h 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. Other meal selections will be added for lunch, dinner and night when the application 4. is readied for beta testing. 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 3. Viewing, editing and printing 4. Viewing, editing and printing an exercise activity 5. Viewing on-line help screens This section outlines the US DA menu food conqx)sition values. chart. that are available at Nutrition/Exercise each menu menu menu functions: (Figure Nutrition 4.2.2 Exercise 4.2.3 Reports 4.2.4 Help (on-line help available Leave (returns a. Level at each menu level.) Main Menu.) Structure Nutrition 4.2.1 The to the Two menu Selecting selections and A18) 4.2.1 4.2.5 level. structure. Nutrition/Exercise causes the screen to display two second-level three plans. Nutrition selection provides access to the food exchange charts, meal planning functions and sub-menu: (Figure USDA Home and Garden Bulletin #72 through the following A 19) 4.3.1 Food Exchanges 4.3.2 Meal Planning 4.3.3 USDA 4.3.4 Help Food Values 85 Nutrition/Exercise Nutrition Figure A18 Exercise Reports Help Nutrition/Exercise Level Two 86 Leave Nutrition Food Exchanges Meal USDA Planning Food Help Values Figure A19 Nutrition/Exercise Level Three 87 Level Three Structure b. Food Exchanges 4.3.1 The Food Exchanges selection provides database through a sub-menu that consists 4.4.1 View/Edit Exchange Charts 4.4.2 DataEntry 4.4.3 Help access to the food exchange A20) View/Edit Exchange Charts 4.4.1 The user Select and press in the selected one record at arrow keys ESC (Figure A21) will queried to enter the ENTER. The exchange. a time. move session, The Up/E>n arrow keys The PgUp/PgDn keys the cursor from must be entered scroll by page. The field to field, horizontally. CTRL-U TAB form and Right/Left F2 wiU complete undo the the last changes made. new records to be entered into the Food Exchange selected, a blank multi-record in are used to scroll through the will DataEntry This selection allows When food exchange to be viewed or edited. screen will then display a form that contains foods listed cancels the session and 4.4.2 same keys (Figure Level Four Structure c. database. of: each field. The cursor as described above. 88 in form will appear on the screen. moved through the form Data by using the Food Exchange View/Edit DataEntry Help Exchange Charts Figure A20 Nutrition/Exercise Level Four 89 [F2] - Data entry cotpleted, Esc - Cancel data entry, Ctrl-U - Undo last change FOOD EtCHANGE CHART Food CANTALOUPE Ex Units .25 |F CARROTS |ielon | .5 |V |cup 1 CASHEWS, NholejO CATSUP | |E |each 6 |V .5 |cup | CELERY STALKS|V .5 | Figure A21 |cup B-Ex F-Ex V-Ex 0-Ex Choi 45|0.0 |0.0 |0.0 |1.0 |0.0 |0.0 | 25|0.0 |0.0 |0.0 |0.0 |0.0 |0.0 j 45|0.0 |0.0 |0.0 |0.0 |0.0 |1.0 1 20|0.0 |0.0 |0.0 jO.O |0.0 |0.0 | 25j0.0 |0.0 |0.0 |0.0 |0.0 |0.0 | 25|0.0 |0.0 jO.O |0.0 |0.0 |0.0 jtsp 2 1 CAULIFLOWER Cals P-Ex H-E fleas | | | Sod 0| 0| | 0| | 0| | | 0| 0| View/Edit Exchange Charts 90 Level Three Structure d. 4.3.2 Meal Planning This selection allows the user to plan, edit or delete daily menus through a sub-menu that contains: (Figure 4.4.4 Menu Design 4.4.5 Edit 4.4.6 Delete Menus Menus Help 4.4.7 e. Level Four Structure 4.4.4 this A22) Menu Design (Figure A23) This selection allows the user to design jjersonal daily menus. Selecting A muhi-table item provides access to the MenuDate, Profiles and MealRecs. screen form that contains the following: 1. 2. 3. A master form that is used to enter date and day to the MenuDate relation. One embedded form used to into the MenuDate relation. One embedded form used enter a patient's personal-data and to enter menu profile food exchange data into the MealRecs relation. The primary function of this through the multi-table/multi-page form. 1. A module is data entry. This is accomplished Data entry operations include: 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 Fl 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. table 91 Meal Planning Menu Edit Delete Design Menus Menus Figure A22 Help Nutrition/Exercise Level Four 92 [F2] - Data entry coapleted, Esc Cancel data entry, Ctrl-U - PgUp/PgDn selects page. For Table Lookup Instructions: Nove cursor to SSN. press F2. to Date ano enter or flove Move to Day a - Fl Press Fl. perfori table lookup. just - Undo last change activates/F2 coipletes data entry. Select recoro froi lookup table ana press the spaceDir for todays date. Press PgDn to enter roods. HENU PLANNING INFORHATION CODES , j SSN: 123-46-1802 nenu Profile for Steve Albert I P I n I 8 - Protein - Hilk I - Bread/Starch ! Fruit Breakfast: 2n.l.5F,lB F - Horning Snack: IF V - I Vegetable Lunch: IP, IB, 10 G - I Oil/Fat Afternoon Snack: IB. IV E - fined/Free Foods Dinner: IB.IMV.ZP Evening Snack: IF A - Breakfast Optional: 16, IR 6 - Horning C • Lunch - Afternoon | j 1 j ; I Snacic I TCals: l^SO 'Zhcl: 600 :200 *5od: D ! E F : Nenu preparation date: Figure A23 Nonaav 2l-Jul-8'9 Menu Design 93 6 Snaci; - Dinner - Evening Snack - Optional j A 2. table lookup function used to enter data from the Foodcx relation into the relation. This is activated when the cursor is placed on the Food MealRecs 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 3. MenuDate Day 4. field. 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 5. 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 The F3 and F4 keys allow embedded form previously as additional capabilities are provided However, some the user to move the cursor from one to another. This allows the user to activate the data entry function for Validity checking the selected form. is provided in two ways: first, through embedded check settings and second through the auxiliary table lookup functions validity described in the Operations section above. to described. by the following keys: The PgUp and PgDn keys allow the user 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 The relations are linked on the key fields SSN and Date. relation. 2. A one-to-many relationship from the Menudate relation to the Profiles The tables are linked 4.4.5 The records. A Edit Edit prompt on the Key field relation. SSN. Menus Menus selection allows selecting and editing of a patient's will ask for the patient's Social Security 94 Number and menu the date that the menu was one that is The screen prepared. used for to the field(s) that Menu you wish will display a multi-table Use Design. to edit form exactly like the the cursor keys (previously described) to and enter the new values. Press F2 to move complete the session. 4.4.6 Menus Delete This selection allows deletion of menus. a prompt /. that queries for the patient's SSN USDA accomplished through and the Date of the record(s) to be deleted. Food Values This selection gives access to the sub-menu selections 4.4.8 View 4.4.9 Help g. is Level Three Structure 4.3.3 Two This USDA USDA Home are provided at this level: (Figure and Garden Bulletin #72. A24) Bulletin Level Four Structure 4.4.8 View USDA Bulletin This function will allows the display and viewing of the entire Home and Garden Bulletin #72. The screen presentation and arrow keys are used to move from through the table a page h. Level 4.2.2 Two at a time. field to field. Press F2 is in tabular form. The PgUp/PgDn keys to return to the USDA The TAB will scroll Main Menu. Structure Exercise TTie Exercise selection allows the access to exercise planning information through the following sub-menu: (Figure A25) 95 USDA Food Values Help View USDA Bulletin Figure A24 Nutrition/Exercise Level Four 96 Exercise Help View/Edit Exercise Chart Figure A25 Nutrition/Exercise Level Three 97 View/Edit Exercise Chart 4.3.5 4.3.6 Help Level Three Structure i. 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. one a time. at move the cursor from Level 4.2.3 scroll The by page. field to field, horizontally. cancels the session and j. The Up/Down arrow keys wUl PgUp/PgDn keys Two CTRL-U will undo the F2 last TAB will (Figure ESC A26) Structure Reports Reports and the Exercise Chart to be printed. 1. through the records complete the session, changes. Allows the Food Exchange Charts, Menus, different reports. scroll and Right/Left arrow keys The source data USDA Food Composition This selection provides access seven for these reports includes: Food Exchange Reports ~ American Diabetes, Association 1988, McMahon and Travis 1984, and Netzer 1988. 2. USDA Food Value Reports -- USDA Home and Garden Bulletin Number 72, 1981. These reports are accessed through the following sub-menu (Figure A27) 4.3.7 Food Exchange Charts 4.3.8 AU Charts 98 selections: [F2] - Data entry coipleted, Esc - Cancel data entry, Ctrl-U - Undo last change EXERCISE CHART Calories Burned Per Hour for Selected Activities Activity llOlbi 1 1301bs I 400 BASKETBALL 415 | 470 540 485 565 I 600 690 635 715 CANOEINE 130 155 180 205 230 CLIHBINB 360 420 485 550 620 CYCLING (LEISURE. 240 CYCLING (RACING) DANCING (PAS') 1 2l51bs 1901bs I701bs ISOlbs I BACrPACHNG 265 305 365 420 510 600 690 780 870 310 365 420 475 535 600 295 DANCING (S.OH) 155 18C 210 235 265 FISHING 185 220 255 290 320 365 GARDENING (DIGGING' 375 445 515 580 650 730 GARDENING (N0KIN6' 355 395 455 515 575 655 60LFING 260 300 350 390 440 500 GYMNASTICS 280 315 360 405 455 515 HORSEBACr RIDING 200 235 270 305 340 399 IRONING 100 115 130 150 170 190 JUDO/KARATE 585 690 795 900 1005 1145 Figure A26 View/Edit Exercise Charts 99 Reports All Food Exchange Charts Charts Figure A27 Your Fats Nutrients Vitamins Help Daily Menu Nutrition/Exercise Level Three 100 Your Daily Menu 4.3.9 4.3.10 Fats 4.3.11 Nutrients 4.3.12 Vitamins 4.3.13 Minerals 4.3.14 Help Level Three Structure k. 4.3.7 Food Exchange Charts This report contains food con^ositions for a selected Food Exchange. A message (Figure will prompt you to enter the food exchange chart that you wish to print. 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. 4.3.9 Your Daily Menu This selection prints the daily menus designed with the function. the menu The user will be for the current 4.3.10 prompted day is for the patient's printed. (Figure SSN. Once this data is entered A29) Fats This report displays the nutritive values of foods in household measures. Once this (Figure is Menu Design The user done, a report is will be commonly used prompted for the food category generated. A30) 101 The to be entered. report contains the following data: FOOD EXCHANGE CHARTS July 10, 1589 . FOOD EXCHANGE: Car Fat E< ANIMAL COOy IBS &A^ED POTATO BEANS, Rea or uhltf BREADCRUMBS, Dr, Figure A28 Food Exchange Charts 102 CM Sod Report ormo*rma. JIjIv U, 1309 , P«g» Total Exchange Units per Food Tot Tot Pooa Measure EX Cals Pro lilk Frt Veg BiS OS.F nENU PREPARED FOR: Steve Albert 11 -Jul -83 ncal: Br ANIMAL COOKIES B BACON F 1.00 each 75 1.00 strip 45 0.0 0.0 0.0 0.0 0.0 1.0 Z.OO each 90 0.0 0.0 1.0 0.0 0.0 0.0 110 0.0 0.0 2.0 0.0 1 0.0 2.0 0.0 1.^ Meal Totals: BEEF BRISKET P 2.00 ID 1.0 . 'J 2.0 Meal Totals: Daily Totals: Figure A29 210 Daily 2.0 Menu 103 Chls Tot Sod August 23, Grouped by Food Category 198S Page Fatty Acids Food Description Heasure Cals Fat Sat Tr Tr Mono Poly Tr. Tr. FOOD CATA60RY: BEVERAGES BEER, Light 12.00 fl oz 95 BEER, Regular 12.00 fl oz 150 CLUB soda 12.00 fl oz COFFEE, Brewed Figure A30 6.00 fl oz Tr Fats 104 Chols 1 Food Description 1. 2. Household Measure 3. Fat in grams 4. Fatty Acids as: a. 5. Saturated in grams grams b. Mono-unsaturated c. Polyunsaturated in grams in Cholesterol in milligrams 4.3.11 Nutrients This report is similar to the one above. 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 43.12 Vitamins Tliis report contains: 1. Food Description 105 However, Nutrients contains the 2. Household measure 3. Calories 4. Vitamin A in international units 5. Vitamin C in milligrams 6. Thiamine 7. Riboflavin 8. Niacin Minerals 4.3.13 This report contains: 1. Food Description 2. Household measure 3. Calories 4. Calcium 5. Phosphorus 6. Iron in milligrams 7. Potassium in milligrams in in 8. Sodium 9. Percent water 5. miUigrams milligrams in milligrams 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 Meal Planning. Dietetic Association, Exchange Lists for 1986. Bochringer Mannheim Manual (Version 1.0). Corporation. Merlin Diabetes Data Management System User's 1988. "Buyer's Guide: Relational Database [dbase in Plus, Paradox, DataBase, R:Base for DOS, Professional Oracle, pp.173-178, November Advanced Revelation: Special]", Personal Computing, v. 12, 1989. Ellenberg, M., "Chronic Complications of Diabetes MeUitus," NY State Journal of Medicine, pp. 2005-2014, December 1979. Feder. Arlene S. "Counting on Computers," Diabetes Forecast, pp. 38-42, 1988. November McMahon. Paula University R.D.. and Travis. Luther B. M.D., Your Daily Meal Plan. of Texas Medical Branch Galveston, Texas. 1988. Miastkowski, Stan, and Nick Baran,"Paradox 109-111, February 1989. Netzer, Corinne T. The Complete 3, Neither Enigma Nor Riddle," Byte, pp. Book of Food Counts. Dell Publishing Co.Jnc, New York, N.Y. 1988. Sprague and Carlson. Building Effective Decision Support Systems. Prentice -Hall, Englewood Cliffs, New Inc., Jersey. 1982. Luther B. An Instructional Aid on Stafford-Lowdon, Fon Worth, Texas. 1985. Insulin-Dependent Diabetes MeUitus. Turban. E. Decision Support and Expert Systems. MacMillan Publishing Co., NY, NY. Travis. 1988. United States Department of Agriculture Handbook Number 451. Nutritive Value of in Common Units. Superintendent of Documents, U.S. Printing Office, Foods Washington. D.C., 1988. 107 United States Department of Agriculture Home Nutritive Values of Foods. Superintendent of Office, Washington, D.C. 198U 108 and Garden Bulletin Number 72. Documents, U.S. Government Printing INITTAL 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 54 Zv) Naval Postgraduate School Monterey, California 93943-5002 Professor Tarek Abdel-Hamid Naval Postgraduate school (Code 54Ah) Monterey, California 93943-5002 Richard A. BIcm 40190 San Carlos Place Frenont, CA 94539 Steven P. Albert 805 2nd Street Pacific Grove, California 93950 109 ^?z A personal-computer b^sed DSS for diabetes ^°ntrol and monitoring 363 35 ^ o ^ -> -h( c.l 3 -. 'j 5 ll ii sis Blow A per3oa£.l-cuv.i^ja^sr based DSS for aic.bates control o.id vnonicoriiig. 1)