**6. Barriers of using HITs in the real-world context and steps to move forward**

While features of HITs can expand patients' ability in diabetes management and the results from the existing research showed their positive effects on outcomes of

HbA1c and CVD risk factors, many of these applications described above have so far been explored predominantly within clinical trials rather than a real-world context. For those that have been widely used in real health-care setting, such as electronic patient record system; both health-care providers and patients have reported difficulties for engagement [50]. Multiple sources of tension contribute to these barriers (**Table 2**).

First of all, the reliability and validity of some HITs is concerning. For example, many manufacturers market their products under the premise that they will help in improving health, but they often do not provide empirical evidence to support the effectiveness of their products [51]. Recent comparisons between different wearable devices for tracking physical activities yielded large heterogeneity in accuracy [52, 53]. The medical apps market also showed the similar discrepancy [54]. Lack of reliability is a serious obstacle that needs to be addressed before a HIT could be considered for medical use. Moreover, whether technological designs incorporated evidence-based guidelines is questionable [55]. It is reported that features of diabetes management apps on the online market did not cover evidence-based recommendations. A recent study evaluated 137 diabetes management apps from two major app stores (iTunes and Google Play) and compared the features with the American Association of Diabetes Educators (AADE) Self-Care Behavior guidelines. The author found an unbalanced feature development of current diabetes management apps. Few apps provided features supporting problem solving, reducing risks, and healthy coping, which are critical for user engagement and successful diabetes self-management [56].

Secondly, the privacy and security of personal data generated by HITs remains problematic. Users of these devices or technologies usually do not own the data; rather, data may be collected and stored by the manufacturers [51]. While some companies are willing to share user's "anonymizing" data via a simple distortion or removal of identifying features, these techniques do not provide adequate levels of anonymity and are not sufficient to prevent identity fraud [57]. Moreover, some devices are easily to be hacked as a result of various communication technologies that aid the transfer of data between the devices and smartphones. It has been reported that wireless digital pacemakers and glucose pumps are vulnerable to cyberattacks [58].

Further, even in relatively widely adopted HIT systems, such as the electronic patient records system, there are still many unfilled promises due to lack of interoperability between systems, difficult-to-use interface, and lack of consideration on patients' backgrounds [50]. In the United States, for example, the patient records


**145**

*Health Information Technologies in Diabetes Management*

systems are not designed to talk to each other [59]. Until now, health-care providers have had little incentive to acquire or develop interoperable systems [50]. As a result, the current electronic health records do not allow a patient or provider to access needed health information anywhere at any time. Additionally, many clinicians are reluctant to invest the considerable time and effort to master difficult-to-use technology, which hindered the anticipated productivity gains of HITs [59]. Moreover, there are limited data collection on patient backgrounds, such as race/ethnicity, language preference, and health literacy in the patient records systems [49]. Lack of this set of data could cause fragmented care delivery and lead to patients' misunder-

standing of provider instruction and lose trust in the medical system [49].

by Medicines and Health Products Regulatory Agency [61].

self-management behaviors of people with diabetes.

implementation of HITs in the real-world setting.

but also will be safer [50].

**7. Conclusion**

To transform HITs a real asset for diabetes care, further steps need to be considered (**Table 2**). First is to create a simple regulatory framework that does not suppress innovation but helps HITs, especially some wearable devices and apps become valid in the context of their health-oriented value [51]. A risk-based classification that promotes innovation, protects patient safety, and avoids regulatory duplications has recently been proposed [60]. As part of this model, the U.S. Food and Drug Administration jurisdiction covers higher-risk medical apps [61]. The National Health Service in the United Kingdom adopts similar pathway with their regulatory framework for mobile apps, which can be classified as "medical devices"

A simple and powerful guide is also needed to transform the HIT system, especially the electronic patient records system. Health data stored in one system should be readily retrievable by others, subject to patient consent [50, 62]. For true interoperability, standardization must be achieved across three dimensions: how messages are sent and received; the structure and format of the information; and terms used within these dimensions [50]. HITs should also facilitate the work of clinicians by providing a system that is intuitive to use and without extensive retraining. Easy-to-use HIT systems not only will increase the productivity of providers

Additionally, HIT systems need to include automated and standardized categories for a patient background (e.g., race/ethnicity, language), facilitate communication among multiple providers and patients, and tailor to the needs of diverse populations [9]. Moreover, a genuine partnership should be fostered between patients and health-care providers through the use of HITs. Engagement can range from patients being simply better informed to individuals themselves being dynamically engaged in the HIT management, giving feedbacks about the HIT interventions, and even controlling who has access to their data [62, 63]. Furthermore, future technologies developed for diabetes management should incorporate balanced features from creditable guidelines to better support changing

Overall, the current evidence shows that HITs have favorable impact on glycemic control and CVD risk management among patients with T2D. Future studies should examine the long-term effects of HITs and their cost-effectiveness, potential harms, and test and verify their effectiveness in glycemic control and other important health indicators such as CVD risk factors, among diverse populations. HITs may be valuable tools in enhancing human health and well-being overall. However, their advances also pose challenges in aspects of validity and reliability, patients' privacy, security, and engagement. These issues need to be addressed before a broader

*DOI: http://dx.doi.org/10.5772/intechopen.83693*

**Table 2.** *Barriers of using HITs in the real-world context and possible solutions.*

#### *Health Information Technologies in Diabetes Management DOI: http://dx.doi.org/10.5772/intechopen.83693*

*Type 2 Diabetes - From Pathophysiology to Modern Management*

diabetes self-management [56].

**Barriers Possible solutions**

cyberattacks [58].

Validity and reliability

Privacy and security

HbA1c and CVD risk factors, many of these applications described above have so far been explored predominantly within clinical trials rather than a real-world context. For those that have been widely used in real health-care setting, such as electronic patient record system; both health-care providers and patients have reported difficulties for engagement [50]. Multiple sources of tension contribute to these barriers (**Table 2**). First of all, the reliability and validity of some HITs is concerning. For example, many manufacturers market their products under the premise that they will help in improving health, but they often do not provide empirical evidence to support the effectiveness of their products [51]. Recent comparisons between different wearable devices for tracking physical activities yielded large heterogeneity in accuracy [52, 53]. The medical apps market also showed the similar discrepancy [54]. Lack of reliability is a serious obstacle that needs to be addressed before a HIT could be considered for medical use. Moreover, whether technological designs incorporated evidence-based guidelines is questionable [55]. It is reported that features of diabetes management apps on the online market did not cover evidence-based recommendations. A recent study evaluated 137 diabetes management apps from two major app stores (iTunes and Google Play) and compared the features with the American Association of Diabetes Educators (AADE) Self-Care Behavior guidelines. The author found an unbalanced feature development of current diabetes management apps. Few apps provided features supporting problem solving, reducing risks, and healthy coping, which are critical for user engagement and successful

Secondly, the privacy and security of personal data generated by HITs remains problematic. Users of these devices or technologies usually do not own the data; rather, data may be collected and stored by the manufacturers [51]. While some companies are willing to share user's "anonymizing" data via a simple distortion or removal of identifying features, these techniques do not provide adequate levels of anonymity and are not sufficient to prevent identity fraud [57]. Moreover, some devices are easily to be hacked as a result of various communication technologies that aid the transfer of data between the devices and smartphones. It has been reported that wireless digital pacemakers and glucose pumps are vulnerable to

Further, even in relatively widely adopted HIT systems, such as the electronic patient records system, there are still many unfilled promises due to lack of interoperability between systems, difficult-to-use interface, and lack of consideration on patients' backgrounds [50]. In the United States, for example, the patient records

> • Incorporating empirical evidence into design development • Being coherent with guidelines from credible sources

tion, protect patient safety, and avoid regulatory duplications

reducing risks, and healthy coping

Adaptability • Building interoperability between systems

preference)

*Barriers of using HITs in the real-world context and possible solutions.*

• Building easy-to-use interface • Providing incentives for engagement

• Evaluating users' needs and improve features on supporting problem solving,

• Considering users' diverse background (language, health literacy, cultural

• Creating regulatory framework and risk-based classifications to promote innova-

**144**

**Table 2.**

systems are not designed to talk to each other [59]. Until now, health-care providers have had little incentive to acquire or develop interoperable systems [50]. As a result, the current electronic health records do not allow a patient or provider to access needed health information anywhere at any time. Additionally, many clinicians are reluctant to invest the considerable time and effort to master difficult-to-use technology, which hindered the anticipated productivity gains of HITs [59]. Moreover, there are limited data collection on patient backgrounds, such as race/ethnicity, language preference, and health literacy in the patient records systems [49]. Lack of this set of data could cause fragmented care delivery and lead to patients' misunderstanding of provider instruction and lose trust in the medical system [49].

To transform HITs a real asset for diabetes care, further steps need to be considered (**Table 2**). First is to create a simple regulatory framework that does not suppress innovation but helps HITs, especially some wearable devices and apps become valid in the context of their health-oriented value [51]. A risk-based classification that promotes innovation, protects patient safety, and avoids regulatory duplications has recently been proposed [60]. As part of this model, the U.S. Food and Drug Administration jurisdiction covers higher-risk medical apps [61]. The National Health Service in the United Kingdom adopts similar pathway with their regulatory framework for mobile apps, which can be classified as "medical devices" by Medicines and Health Products Regulatory Agency [61].

A simple and powerful guide is also needed to transform the HIT system, especially the electronic patient records system. Health data stored in one system should be readily retrievable by others, subject to patient consent [50, 62]. For true interoperability, standardization must be achieved across three dimensions: how messages are sent and received; the structure and format of the information; and terms used within these dimensions [50]. HITs should also facilitate the work of clinicians by providing a system that is intuitive to use and without extensive retraining. Easy-to-use HIT systems not only will increase the productivity of providers but also will be safer [50].

Additionally, HIT systems need to include automated and standardized categories for a patient background (e.g., race/ethnicity, language), facilitate communication among multiple providers and patients, and tailor to the needs of diverse populations [9]. Moreover, a genuine partnership should be fostered between patients and health-care providers through the use of HITs. Engagement can range from patients being simply better informed to individuals themselves being dynamically engaged in the HIT management, giving feedbacks about the HIT interventions, and even controlling who has access to their data [62, 63]. Furthermore, future technologies developed for diabetes management should incorporate balanced features from creditable guidelines to better support changing self-management behaviors of people with diabetes.
