**4. mHealth challenges in patient monitoring**

and others implemented on mobile phone. Sending alarm to patients and health care providers and identify place of patients with GPS are possible in some of the studied systems. Wired and wireless communication in all system studied can be useful especially when mobility is

Recently, health care systems shift toward fast achieving to right decision to solve problems with spending least costs. So to reach this goal, find suitable information from useful and reliable resources in the fastest time and the least possible effort for information searching,

This requires high interoperability among different professionals and systems in various places. In fact for providing effective health care and shared information, all actions need to be coordinated. Facilitated decision making requires interoperability and effective communi‐ cations between professionals. Finding standard software as a suitable solution for complex health challenges is not easy. Electronic health systems must be proactive in anticipating the

Because of potential capabilities of agent technology like mobility [44], autonomy, interoper‐ ability, scalability and re-configurability, integrating disparate systems, improving distributed data and resources management, handling the complexity of solutions, modeling and organ‐ izing the interrelationships between components [31–36, 46–51], is very valuable tool for

Agent-based systems in this table increase quality of care management. For example in IMIS system, tasks were delegated and all users in each level can communicate with one another and share the relevant data. In M2DM system, various analytic ways through knowledge agent were combined and used for the identification of abnormal situations. Also sending alarms, analysis results and real-time feedbacks to users are some benefits of this system [31–36]. Agents can be implemented on portable and mobile devices like PDA and use web services to

The IMIS platforM is based on the Internet and will be accessible by PC or wireless network PDA. Accessibility should be regulated by groups of users. Each step in this system by the user is followed with instant feedback. M2DM can be activated in three ways: based on user needs, with receiving data, and by system. This system uses inexpensive and widely accepted technologies. This system applies technologies such as WEB, WEB TV, and SMS that are supported with computers or mobile terminals. Also it combines innovative and advanced technologies like PDA, WAP, GPRS, and PALMTOPS. The use of such technologies is limited

Overall, according to multiagent health systems advantages in comparison to other type of systems and challenges in health care systems especially in diabetics care management, it can be said that the use of agent technology as a new and modern technology to reach full advantages of telemedicine and telehealth is essential, and health systems in the world must

in small groups of users because of costs, accessibilities, and user skills required.

desired.

analyzing, and filtering is very important.

84 Mobile Health Technologies - Theories and Applications

telemedicine and telecare.

interact with other systems.

move toward agent-based applications.

health information needs and supporting communications.

Although mHealth technology has a key role in health care systems, yet its uptake has faced with general and specific challenges. Some problems in general dimension include organiza‐ tional challenges like organizational culture, support of high-level management; technological barriers such as lack of ICT and mobile infrastructure [52]; human challenges, for example, lack of trained and skilled personnel at health care centers in this field [28], user attitudes, technology acceptance [53, 54], user characteristics like age, economic, social, and educational status [55]; and threats to confidentiality and privacy, legal, ethical, and administrative barriers, costs of system implementation and maintenance [28], dependence on IT [56], the cost of updating, costly modern systems [57], sufficient investment, delays in implementation and providing electronic devices and software [58]. Some barriers from specific aspects also include problems in interoperability between other health systems and information technology tools, poor and inappropriate design and implementation [59], effect on face-to-face communication between health care providers and patient [60], causes omission of human relationship and the negative effects of technology on relationships between individuals and social processes [56], designing of mHealth services content [55], failure to meet targets [58], virtual information control [61], medical errors due to malfunctioning of system [62], fault documentation [59] like data manipulation and rewriting, misrepresentation, and violation of patients' legal rights. Difficulties related to telecommunication industry such as reliability, sustainability of connec‐ tions, sudden interruptions of telecommunication networks [63], device and sensor type that can be used, type of data and language presentation [56], scalability in terms of data rate, power and energy consumption; antenna design, quality of service, energy efficiency [64, 65] wearable devices weight, type of devices that used for patient monitoring that sometimes lead to problem in data processing, accuracy of gathering information depends on where data were collected, and user training to use wearable system [66].

As aforementioned, one of the items that can help mHealth infrastructure development is application of agent-based systems in patient monitoring. We perform research in Iran about diabetes as one of the most challenging chronic diseases. The aim of this research is developing framework for agent-based diabetes disease management system through mHealth according to user's perspective. Some of the most important results are as follows:

## **5. Case study**

Endocrinology and metabolism research institute of Tehran University of Medical Sciences in collaboration with Health Information Management Research center in this University conducted a research in 2012–2013. The goal of this research was to provide a model based on mobile health and agent technology in national level for diabetes management information. This framework must have capabilities of agent and support decision-making, create alerts and remote monitoring of patient status, and provide appropriate treatment and preventive recommendations for diabetes.

A questionnaire was designed with a study of library resources and operation of major organizations in and out of the country and interviews with relevant medical experts.

To determine the validity of a questionnaire distributed among experts in three areas after analyzing the results, the reliability was evaluated. Questionnaire includes three parts. First section covers personal identification. Second section questions about the general features of agent-based systems for the management of diabetes. Finally, third section examines the specific features of the systems in hospitals. At the end of questionnaire, an open question captured the opinions of experts concerning diabetes management system structure based on agent technology. Results of the questionnaires were analyzed with SPSS17 and were plotted with FREEPLANE mind map software. Finally, essential agents according to tasks of diabetes management system were determined. Some of the results obtained from this study are explained below.

Most diabetics must monitor and measure their blood glucose levels during the day. Like measuring glucose after every insulin injection and record it, along with the amount of daily insulin injections and diet and information about their lifestyle. Using information technology tools and a telemedicine system helps process management of health service, allows real-time monitoring, and provides early treatment for diabetes. To achieve these goals are possible through multi agent systems can be performed with using different agents. Based on this study, a diabetes management system has necessary business process including:


Important services and processes through the implementation of software systems in the field of diabetes management from the experts, perspectives are plotted (see **Figure 1**).

From the experts' point of view in this research, proposed framework must be used in priority order for home care, outpatient, and inpatient. Best development method to such system in priority order is telemonitoring or teletreatment services, user centered, merging of telemedi‐ cine with knowledge management, local and personal health services. Access to data technol‐ ogy in this system in priority order is mobile, SMS, Email, Internet in devices including web, phone, WIFI, and PDA. Also according to studies, to provide better health services, the communication should be used through wired or wireless connection tools.

**Figure 1.** Software necessary for health care delivery electronic systems for diabetic patients.

A questionnaire was designed with a study of library resources and operation of major

To determine the validity of a questionnaire distributed among experts in three areas after analyzing the results, the reliability was evaluated. Questionnaire includes three parts. First section covers personal identification. Second section questions about the general features of agent-based systems for the management of diabetes. Finally, third section examines the specific features of the systems in hospitals. At the end of questionnaire, an open question captured the opinions of experts concerning diabetes management system structure based on agent technology. Results of the questionnaires were analyzed with SPSS17 and were plotted with FREEPLANE mind map software. Finally, essential agents according to tasks of diabetes management system were determined. Some of the results obtained from this study are

Most diabetics must monitor and measure their blood glucose levels during the day. Like measuring glucose after every insulin injection and record it, along with the amount of daily insulin injections and diet and information about their lifestyle. Using information technology tools and a telemedicine system helps process management of health service, allows real-time monitoring, and provides early treatment for diabetes. To achieve these goals are possible through multi agent systems can be performed with using different agents. Based on this study,

**7.** Appropriate interface for communication between patients and health electronic systems

Important services and processes through the implementation of software systems in the field

From the experts' point of view in this research, proposed framework must be used in priority order for home care, outpatient, and inpatient. Best development method to such system in priority order is telemonitoring or teletreatment services, user centered, merging of telemedi‐ cine with knowledge management, local and personal health services. Access to data technol‐ ogy in this system in priority order is mobile, SMS, Email, Internet in devices including web, phone, WIFI, and PDA. Also according to studies, to provide better health services, the

**8.** Monitoring operations and service delivery and allocate tasks to perform

communication should be used through wired or wireless connection tools.

of diabetes management from the experts, perspectives are plotted (see **Figure 1**).

a diabetes management system has necessary business process including:

**5.** Archiving relevant documents and patient records

organizations in and out of the country and interviews with relevant medical experts.

explained below.

86 Mobile Health Technologies - Theories and Applications

**1.** Information processing

**2.** Monitor patient status

**6.** Decision support system

**3.** Consultation

**4.** Diagnosis

Capabilities for diabetes management system based on agent technology in medical centers and hospitals section based on research findings with FREE PLANE software are depicted in **Figure 2**.

Also capabilities for diabetes management system based on agent technology for health care personnel based on research findings are: (1) remote education, (2) knowledge management, (3) intelligent alarms, and (4) electronic health records management. From the experts' point of view, diabetes management system based on agent technology must have these abilities for patients in the following order: (1) remote education, (2) intelligent alarms and reminders, (3) patient monitoring, (4) self-management, and (5) determining the exact location of medical centers and hospitals.

**Figure 2.** Capabilities necessary for mobile diabetes management system for hospitals and health care centers.

Experts in this research believed that proposed framework must be delivered through remote education to diabetes patients. Suitable remote education formats recommended in order of priority include imaging, audio, model questions and answers, and text tutorials. Patients on remote education should be able to search based on their needs, choice of content, and personalization and have the possibility to download the contents.

The weakness of this project is that benefits of experts surveyed only from health information management, software and physician in diabetic research center fields. To design and implement more appropriate conceptual models, involved experts should be from various fields such as telecommunication and addressing various aspects are very helpful, and the gained result is a more practical.

## **6. Discussion**

Nowadays real-time access to reliable and proper information in order to deliver continuous health care and increase quality of care is very much in demand. So in order to achieve this goal, interoperability and coordination among providers involved in patient treatment for exchange of health information is a critical need. Chronic disease management especially diabetes based on IT tools has impressive benefits and some challenges. In this chapter, diabetic management system is classified into two groups: agent-based system and nonagent-based system.

Better self-care, improved prevention, increased quality life style, and teleconsultation are most important benefits of nonagent-based systems. Also these systems confront some challenges. The use of agent systems as a modern technology to decrease these barriers and take full advantages of telemedicine is essential and health systems must move using agentbased applications. In the second group, some of the benefits of agent technology in teleme‐ dicine services delivery include providing immediate feedback to patients, promoting interaction of the patient with organization that provides remote health care, reinforcing their motivation for the use of telemedicine systems and patients, and clinicians focusing on abnormal data that will prevent future occurrence of dangerous situations.

Agent-based systems improve interoperability, maintain the autonomy of the collaborating participants, communicate between themselves for exchanging health information, provide expert knowledge management, and improve e-learning. Multiagent systems are inherently compatible with mobile devices. Architecture of these systems allows high interoperability and quality information management and appropriate sharing data. Diabetes virtual clinic in Iran is one of the nonagent systems that provides some important health services to the people and assist them to improve knowledge about diabetes care. This system needs to move toward the use of artificial intelligence tools and expert systems like agents for further development and increased capabilities. Our finding in 2013 research showed that to accelerate the devel‐ opment of diabetes management systems based on artificial intelligence tools, we must consider these items: (1) promote organizational cultural, (2) note to suitable technical infrastructure, (3) provide appropriate security and privacy, (4) adequate investment, (5) user participation, and (6) involvement of private sections. Also note to structure, proper system, and database design that can support different kinds of training formats and tasks, and provide backup are very important. Ease of use and user friendliness of system should be considered especially for elderly people. Also design of drug and injection reminders for patients in addition to the built-in alarm system is a key factor.

It should be noted that the use of agent systems only with technical view does not lead to elimination of obstacles. In delivering health care to diabetic patients or other chronic disease patients, paying attention to human aspect and social dimension is very important. Some users dislike computers and do not trust them. So these challenges in designing diabetes system based on mobile devices must be considered. In other words, note to all dimensions for implementation of mobile health systems especially agent system like user satisfaction, user acceptance, costs, motivation, structural and organizational factors, and standards, individu‐ al's affordability, identification challenges and opportunity, and so on are necessary. Also accelerating the application and implementation of multiagent diabetes management systems and use of mobile devices need to development of strategies to encourage health care providers for make greater use of mobile devices in deliver health care services to patients and providing the necessitate infrastructure and appropriate readiness. Stakeholders' support to apply of agent technology is essential.
