Further user comments regarding usage of an interactive educational diabetes simulator (AIDA)

Dynamic Interactive Educational Diabetes Simulations Using the World Wide Web: An Experience of More Than 15 Years with AIDA Online

Background. AIDA is a widely available downloadable educational simulator of glucose-insulin interaction in diabetes. Methods. A web-based version of AIDA was developed that utilises a server-based architecture with HTML FORM commands to submit numerical data from a web-browser client to a remote web server. AIDA online, located on a remote server, passes the received data through Perl scripts which interactively produce 24 hr insulin and glucose simulations. Results. AIDA online allows users to modify the insulin regimen and diet of 40 different prestored "virtual diabetic patients" on the internet or create new "patients" with user-generated regimens. Multiple simulations can be run, with graphical results viewed via a standard web-browser window. To date, over 637,500 diabetes simulations have been run at AIDA online, from all over the world. Conclusions. AIDA online's functionality is similar to the downloadable AIDA program, but the mode of implementation and usage is different. An advantage to utilising a server-based application is the flexibility that can be offered. New modules can be added quickly to the online simulator. This has facilitated the development of refinements to AIDA online, which have instantaneously become available around the world, with no further local downloads or installations being required.

Incorporating a generic model of subcutaneous insulin absorption into the AIDA v4 diabetes simulator: 1. a prospective collaborative development plan

INTRODUCTION

AIDA v4 is an interactive educational diabetes simulator that has been made available, for over a decade, without charge via the Internet. The software is currently freely accessible at http://www.2aida.org. This report sets out a collaborative development plan to enhance the program with a new model of subcutaneous insulin absorption, which permits the simulation of rapidly acting and very long-acting insulin analogues, as well as insulin injection doses larger than 40 units.

METHODS

A novel, generic, physiological subcutaneous insulin absorption model is overviewed and a methodology is proposed by which this can be substituted in place of the previously adopted insulin absorption model utilized within AIDA v4.3a. Apart from this substitution it is proposed to retain the existing model of the glucoregulatory system currently used in AIDA v4.3a.

RESULTS

Initial simulation results based on bench testing of this approach using MATLAB are presented for the exogenous insulin flow profile (I(ex)) following subcutaneous injections of a rapidly acting insulin analogue, a short-acting (regular) insulin preparation, intermediate-acting insulins (both Semilente and neutral protamine Hagedorn types), and a very long-acting insulin analogue.

DISCUSSION

It is proposed to implement this collaborative development plan-first by bench testing the approach in MATLAB and then by integrating the generic subcutaneous insulin absorption I(ex) model into the AIDA simulator in Pascal. The aim is to provide enhanced functionality and educational simulations of regimens utilizing novel insulin analogues, as well as injections larger than 40 units of insulin.

The Särimner diabetes simulator--a look in the rear view mirror

BACKGROUND

At the end of the 1980s, the Department of Pediatrics at Linköping University, Linköping, Sweden developed a computerized diabetes simulator. The main purpose was to allow teenagers with Type 1 diabetes to experiment with food, exercise, and insulin without the risk of inconvenience. The aim of this paper is to discuss experiences from the previous work with teenagers on the Särimner diabetes simulator.

METHODS AND RESULTS

In 1991, shortly before Sweden became computerized, the impact of the simulator was evaluated in a study with 11 teenagers. Improvements were seen in a few individuals regarding locus of control, self-esteem, diabetes knowledge, and diabetes-related stress, but could not be shown on a group level. The simulator was used for longer periods at some clinics, also by individual health professionals and in a diabetes camp, but support for further development has been lacking. It was also used in modeling projects of Type 2 diabetes and obesity.

CONCLUSIONS

Proactive pedagogic measures may find it hard to compete with corrective technological measures since their effectiveness is more difficult to prove by scientific methods. Nevertheless, they are needed together with other methods to improve understanding and motivation in the treatment of Type 1 diabetes.

Development of a PC-based diabetes simulator in collaboration with teenagers with type 1 diabetes

BACKGROUND

The main aim of this study was to develop and test in a pilot study a PC-based interactive diabetes simulator prototype as a part of future Internet-based support systems for young teenagers and their families. A second aim was to gain experience in user-centered design (UCD) methods applied to such subjects.

METHODS

Using UCD methods, a computer scientist participated in iterative user group sessions involving teenagers with Type 1 diabetes 13-17 years old and parents. Input was transformed into a requirements specification by the computer scientist and advisors. This was followed by gradual prototype development based on a previously developed mathematical core. Individual test sessions were followed by a pilot study with five subjects testing a prototype. The process was evaluated by registration of flow and content of input and opinions from expert advisors.

RESULTS

It was initially difficult to motivate teenagers to participate. User group discussion topics ranged from concrete to more academic matters. The issue of a simulator created active discussions among parents and teenagers. A large amount of input was generated from discussions among the teenagers. Individual test runs generated useful input. A pilot study suggested that the gradually elaborated software was functional.

CONCLUSIONS

A PC-based diabetes simulator may create substantial interest among teenagers and parents, and the prototype seems worthy of further development and studies. UCD methods may generate significant input for computer support system design work and contribute to a functional design. Teenager involvement in design work may require time, patience, and flexibility.

Diabetes website review: www.2aida.org

Previous Diabetes Information Technology & WebWatch columns have addressed the use of diabetes simulators, and, in particular, aspects of the AIDA software. AIDA is a freeware computer program, which simulates the interaction of carbohydrates and insulin administered in people with insulin-dependent (type 1) diabetes mellitus. The program is intended to be used as an educational support tool, and is available via the Internet without charge from www.2aida.org. In this article, the AIDA Website is described and reviewed in terms of both content and functionality. This popular non-commercial Internet site provides free access to a downloadable PC version of AIDA, as well as access to a Web-based version of the simulator that can be run online (accessible directly at: www.2aida.net). User feedback suggests that the Website and the AIDA software have been of significant interest and value to many patients, their relatives and carers, students, and a variety of health-care professionals and researchers. The interactive and dynamic nature of the simulations adds a real-life dimension to the Web-based educational material, and the software is complemented by a substantial amount of supporting information at the Website. The on-going collection of subjective feedback continues to provide anecdotal evidence of the utility of the software, and this will hopefully be corroborated by results from more formal and objective evaluations. The future potential of diabetes simulators, in both education and research, is becoming increasingly apparent, and the AIDA Website is evolving accordingly.

The DAILY (Daily Automated Intensive Log for Youth) trial: a wireless, portable system to improve adherence and glycemic control in youth with diabetes

Blood glucose (BG) monitoring (BGM) is an important component of diabetes management. New wireless technologies may facilitate BGM and help to optimize glycemic control. We evaluated an integrated wireless approach with and without a motivational game in youth with diabetes. Forty youth, 8-18 years old, each received a handheld device fitted with a wireless modem and diabetes data management software, plus a wireless-enabled BG monitor. Half were randomized to receive the new technologies along with an integrated motivational game in which the participants would guess a BG level following collection of three earlier readings (Game Group). BG data, insulin doses, and carbohydrate intake were displayed graphically prior to the glucose estimation. The other group received the new technologies alone (Control Group). Both groups were instructed to perform BGM four times daily and transmit their data to a central server via the wireless modem. Feasibility of implementation and outcomes were ascertained after 4 weeks. Ninety-three percent of participants successfully transmitted their data wirelessly to the server. The Game Group transmitted significantly more glucose values than the Control Group (P < 0.001). The Game Group also had significantly less hyperglycemia (glucose >/=13.9 mmol/L or >/=250 mg/dL) than the Control Group (P < 0.001). Youth in the Game Group displayed a significant increase in diabetes knowledge over the 4-week trial (P < 0.005). Finally, there was a trend for more youth in the Game Group to maintain hemoglobin A1C values </=8% (P = 0.06). Thus a pediatric population with diabetes can successfully implement new technologies to facilitate BGM. Use of a motivational game appears to increase the frequency of monitoring, reduce the frequency of hyperglycemia, and improve diabetes knowledge, and may help to optimize glycemic control.

Why people download the freeware AIDA v4.3a diabetes software program: a proof-of-concept semi-automated analysis

AIDA is a diabetes-computing program freely available at www.2aida.org on the Web. The software is intended to serve as an educational support tool and can be used by anyone who has an interest in diabetes, whether they be patients, relatives, health-care professionals, or students. In previous "Diabetes Information Technology & WebWatch" columns various indicators of usage of the AIDA program have been reviewed, and various comments from users of the software have been documented. The purpose of this column is to overview a proof-of-concept semi-automated analysis about why people are downloading the latest version of the AIDA educational diabetes program. AIDA permits the interactive simulation of plasma insulin and blood glucose profiles for teaching, demonstration, self-learning, and research purposes. It has been made freely available, without charge, on the Internet as a noncommercial contribution to continuing diabetes education. Since its launch in 1996 over 300,000 visits have been logged at the main AIDA Website-www.2aida.org-and over 60,000 copies of the AIDA program have been downloaded free-of-charge. This column documents the results of a semi-automated analysis of comments left by Website visitors while they were downloading the AIDA software, before they had a chance to use the program. The Internet-based survey methodology and semi-automated analysis were both found to be robust and reliable. Over a 5-month period (from October 3, 2001 to February 28, 2002) 400 responses were received. During the corresponding period 1,770 actual visits were made to the Website survey page-giving a response rate to this proof-of-concept study of 22.6%. Responses were received from participants in over 54 countries-with nearly half of these (n = 194; 48.5%) originating from the United States, United Kingdom, and Canada; 208 responses (52.0%) were received from patients with diabetes, 50 (12.5%) from doctors, 49 (12.3%) from relatives of patients, with fewer responses from students, diabetes educators, nurses, pharmacists, and other end users. The semi-automated analysis adopted for this study has re-affirmed the feasibility of using the Internet to obtain free-text comments, at no real cost, from a substantial number of medical software downloaders/users. The survey has also offered some insight into why members of the public continue to turn to the Internet for medical information. Furthermore it has provided useful information about why people are actually downloading the AIDA v4.3a interactive educational "virtual diabetes patient" simulator.

Usage of the www.2aida.org AIDA diabetes software Website: a pilot study

AIDA is a diabetes-computing program freely available from www.2aida.org on the Web. The software is intended to serve as an educational support tool, and can be used by anyone who has an interest in diabetes, whether they be patients, relatives, health-care professionals, or students. In previous "Diabetes Information Technology & WebWatch" columns various indicators of usage of the AIDA program have been reviewed, and various comments from users of the software have been documented. One aspect of AIDA, though, that has been of considerable interest has been to investigate its Web-based distribution as a wider paradigm for more general medically related usage of the Internet. In this respect we have been keen to understand in general terms: (1) why people are turning to the Web for health-care/diabetes information; (2) more specifically, what sort of people are making use of the AIDA software; and (3) what benefits they feel might accrue from using the program. To answer these types of questions we have been conducting a series of audits/surveys via the AIDA Website, and via the software program itself, to learn as much as possible about who the AIDA end users really are. The rationale for this work is that, in this way, it should be possible to improve the program as well as tailor future versions of the software to the interests and needs of its users. However, a recurring observation is that data collection is easiest if it is as unobtrusive and innocuous as possible. One aspect of learning as much as possible about diabetes Website visitors and users may be to apply techniques that do not necessitate any visitor or user interaction. There are various programs that can monitor what pages visitors are viewing at a site. As these programs do not require visitors to do anything special, over time some interesting insights into Website usage may be obtained. For the current study we have reviewed anonymous logstats data, which are automatically collected at many Websites, to try and establish a baseline level of usage for the AIDA site. For the initial pilot study the analysis was performed from October 1, 2000 to November 1, 2001. The study has yielded an interesting insight into how the AIDA Website is being used. The results also confirm those of previous audits based on different self-reported methodologies, confirming, amongst other things, what countries people are visiting from and what operating systems/computers they are using. These analyses have been informative and useful. Given this, it is proposed to repeat the current pilot survey approach on a routine basis, in the future, as a way of monitoring on-going usage of the AIDA Website.

Why are people downloading the freeware AIDA diabetes computing software program: a pilot study

The purpose of this paper is to report a pilot survey about why people are downloading the AIDA interactive educational diabetes simulator. AIDA is a diabetes computer program that permits the interactive simulation of plasma insulin and blood glucose profiles for teaching, demonstration, and self-learning purposes. It has been made freely available, without charge, on the Internet as a noncommercial contribution to continuing diabetes education. Since its launch in 1996 well over 200,000 visits have been logged at the main AIDA Website--www.2aida.org--and over 40,000 copies of the AIDA program have been downloaded free-of-charge. This article documents a pilot survey of comments left by Website visitors while they were downloading the AIDA software, before they had a chance to actually use the program. The overall paradigm adopted for this study has endeavored to establish why people are resorting to the Internet to obtain diabetes information. Specific intended goals of the study were: (1) to demonstrate ongoing use of the World Wide Web for surveying diabetes software users by obtaining their free-text comments; (2) to identify what sort of things people were planning to do with the AIDA software simulator; and (3) to more generally gain some insight into why people are turning to the Web for healthcare-related information. The Internet-based survey methodology was found to be robust and reliable. Over an 8-month period (from February 2, 2001 to October 1, 2001) 642 responses were received. During the corresponding period 2,248 actual visits were made to the Website survey page--giving a response rate to this pilot study of 28.6%. Responses were received from participants in over 56 countries--although over half of these (n = 343; 53.4%) originated from the United States and United Kingdom. Two hundred forty-four responses (38.0%) were received from patients with diabetes, and 73 (11.4%) from relatives of patients, with fewer responses from doctors, students, diabetes educators, nurses, pharmacists, and other end users. This pilot survey has confirmed the feasibility of using the Internet to obtain free-text comments, at no real cost, from a large number of medical software downloaders/users. The survey has also offered a valuable insight into why members of the public are turning to the Internet for medical information. Furthermore it has provided useful information about why people are actually downloading the AIDA interactive educational "virtual diabetes patient" simulator.

Using the AIDA--www.2aida.org--diabetes simulator. Part 1: recommended guidelines for health-carers planning to teach with the software

AIDA is a novel diabetes-computing program freely available from www.2aida.org on the Web. The software is intended to serve as an educational support tool and can be used by anyone-patient with diabetes, relative of patient, health-care professional, or student-who has a minimal knowledge of the pathophysiology of diabetes. However, to obtain maximum benefit from the program, a teacher or demonstrator may be helpful. How much (or little) experience should the potential teacher have prior to giving formal lessons with the program? There is no hard or fast "rigid" answer to this. However, one of the aims of this article is to try and encourage people to consider these issues. In this respect it is important to make clear that health-carers cannot just download the program and start teaching with it the next day (or week) if they want their patients to get the most out of lessons with the program. As with many teaching interventions, the rewards of education-"what one gets out of it"-are in part dependent on the effort that one is willing to put in. Therefore teachers have to invest some time and effort into finding out how they can best work with the program to teach their patients in their particular local hospital/clinic setting. A further purpose of this article, and the one that follows in a future issue, is to generate some guidelines and provide some minimum recommendations for small group teaching sessions using AIDA. Previous experience of the authors has revealed a number of ways to improve the outcome of lessons that make use of the software. Among the most important points seem to be the preparation of the teacher, consideration of how to impart preliminary information to help patients understand the pathophysiology of diabetes, the optimum selection of topics to be covered, the arrangement of the lessons, how to involve each of the participants, and how to deal with questions. Other important topics include how to spot and deal with some of the difficulties that may be encountered by participants who apparently seem disinterested, obtaining feedback from the lessons, and practical ideas on how to lead a class.

Using the AIDA--www.2aida.org--diabetes simulator. Part 2: recommended training requirements for health-carers planning to teach with the software

The purpose of this article is to document some recommended training requirements for health-carers planning to teach using the AIDA interactive educational diabetes simulator. AIDA is a diabetes computer program that permits the interactive simulation of plasma insulin and blood glucose profiles for teaching, demonstration, and self-learning purposes. It has been made freely available, without charge, on the Internet as a noncommercial contribution to continuing diabetes education. Since its launch in 1996 over 200,000 visits have been logged at the AIDA Website--www.2aida.org--and over 40,000 copies of the AIDA program have been downloaded free-of-charge. This report describes various training requirements that are recommended for health-care professionals who are interested in teaching with the software. Intended goals of this article are to answer possible questions from teachers using the program, highlight some minimum recommended training requirements for the software, suggest some "hints and tips" for teaching ideas, explain the importance of performing more studies/trials with the program, overview randomised controlled trial usage of the software, and highlight the importance of obtaining feedback from lesson participants. The recommendations seem to be straightforward and should help in formalising training with the program, as well as in the development of a network of teachers "accredited" to give lessons using the software. This report, together with the previous article (Part 1, Diabetes Technol Ther 2002;4:401-414), highlights the utility of providing guidelines and suggesting recommended training requirements for health-carers planning to make use of educational medical/diabetes software.

Who is downloading the freeware AIDA v43 interactive educational diabetes simulator? An audit of 2437 downloads

The purpose of this paper is to report an audit of 2437 downloads of the AIDA interactive educational diabetes simulator. AIDA is a diabetes computer program that permits the interactive simulation of plasma insulin and blood glucose profiles for educational, demonstration, and self-learning purposes. It has been made freely available, without charge, on the Internet as a noncommercial contribution to continuing diabetes education. Since its launch in 1996 over 200000 visits have been logged at the AIDA Website - www.2aida.org - and over 37000 copies of the AIDA program have been downloaded free-of-charge. This report documents an audit of downloaders of the software, with the intended goals of the study being to demonstrate the use of the Internet for auditing and surveying diabetes software users and to confirm the proportion of patients with diabetes and their relatives who are actually making use of the AIDA v4.3 program. The Internet-based survey methodology was confirmed to be robust and reliable. Over a 7(1/2)-month period (from mid-July 2000 to early March 2001) 2437 responses were received. During the corresponding period 4100 actual downloads of the software were independently logged via the same route at the AIDA Website - giving a response rate to this audit of 59.4%. Responses were received from participants in 61 countries - although over half of these (n = 1533; 62.9%) originated from the United States and United Kingdom. Of these responses 1,361 (55.8%) were received from patients with diabetes and 303 (12.4%) from relatives of patients, with fewer responses from doctors, diabetes educators, students, nurses, pharmacists, and other end users. This study has confirmed the feasibility of using the Internet to survey, at no real cost, a large number of medical software downloaders/users. In addition, it has yielded up-to-date and interesting data about who are the main downloaders of the AIDA program.