Can J Diabetes 39 (2015) 200e203
Contents lists available at ScienceDirect
Canadian Journal of Diabetes
journal homepage:
www.canadianjournalofdiabetes.com
Innovations in Diabetes Care
A Smartphone-Based Cloud Computing Tool for Managing
Type 1 Diabetes in Ontarians
Vikraman Baskaran PhD a, Franklyn Prescod PhD b, *, Linying Dong PhD b
a
Penfield College, Mercer University, Atlanta, Georgia, USA
b
Ted Rogers School of Management, Ryerson University, Toronto, Ontario, Canada
Introduction
Diabetes caused by hyperglycemia has been classified as a
pandemic chronic disease by the World Health Organization (1),
has been reported in more than 180 million cases worldwide (1),
and may continue to increase in the next 15 years (2,3). Diabetes-
related conditions in Ontario, Canada, are not being monitored or
managed as expected, which may result in major complications for
1 in 20 patients with diabetes within a year (4). Patients with
diabetes in Ontario have been found to have reduced life expec-
tancies by nearly 13 years when compared to those of people
without diabetes (5). There are 3 types of diabetes: type 1, type 2
and gestational diabetes. Although there have been a number of
studies that have tried to address type 2 diabetes mellitus (6e11),
type 1 diabetes has been studied relatively less from the perspec-
tive of personal disease management. However, compared to type 2
diabetes, type 1 has to be more thoroughly managed to avoid long-
term complications in the eyes, the kidneys and the cardiovascular
and cognitive systems. The effective management of type 1 dia-
betes is challenging because patients with type 1 diabetes are
normally young children, adolescents and young adults who,
despite their lack of knowledge about the disease and the medical
implications of the disease, are responsible for handling complex
treatments, such as insulin pumps and maintaining proper glyce-
mic levels and required physical activities. Although there is an
abundance of information, and it is easy to access information
about type 1 diabetes, self-management of this disease in adoles-
cents is strongly associated with peer support (6). A lack of peer
support effectively results in lower-than-optimal levels of man-
agement of type 1 diabetes (6).
Daneman reports that in Canada, type 1 diabetes accounts for 5%
to 10% of all cases of the disease (7). The self-management of type 1
diabetes has to incorporate 2 kinds of situations: 1) crisis situations
caused by hypoglycemia and 2) managing proper glycemic levels. A
crisis situation due to hypoglycemia often is associated with loss of
consciousness and seizures, commonly referred to as diabetic coma
(diabetic ketoacidosis) and, eventually, a fall in many cases (8,9). If
* Address for correspondence: Franklyn Prescod, PhD, Ted Rogers School of
Management, Ryerson University, 350 Victoria Street, Toronto, Ontario M5B 2K3
Canada.
E-mail address: fprescod@ryerson.ca
1499-2671/$ e see front matter Ó 2015 Canadian Diabetes Association
http://dx.doi.org/10.1016/j.jcjd.2015.04.002
immediate care is not available to patients with diabetes, there is a
risk for permanent brain damage and even death in severe cases
(8,9). The current research develops a health informatics platform
based on Cloud-computing technologies that offer an integrated
toolset that will keep track of type 1 diabetes management.
Cloud Computing and the Canadian Healthcare System
Chronic diseases have put undue pressure not only on the
underdeveloped and developing nations but also on developed
nations such as the United States, the United Kingdom, Australia
and Canada. The Canadian healthcare system is already faced with
the challenge of delivering quality and overall efficient healthcare
effectively. Healthcare costs increase by more than 5% a year and
are expected to rise with the aging population (5). The majority of
Canadians believe that the healthcare system is “unsustainable and
urgently in need of substantive change” (13).
Traditional healthcare interventions, such as those offered by
family physicians, pediatricians, and diabetes management teams
are unsustainable. Modern interventions (such as the solution
proposed here) rely strongly on sustainable and comprehensive
diabetes care through patient empowerment. Even though a
number of important factors, such as lifestyle behaviour, self-care,
role clarification, conflict, patient engagement and adherence,
play important roles in managing diabetes effectively, collaboration
plays a pivotal role in achieving therapeutic goals (14). This article
describes and assesses such an innovative and multipronged
innovative application to managing type 1 diabetes.
Sustainable diabetes care can be empowered greatly by adopt-
ing newer and easier-to-implement technology-based solutions.
Traditional information-sharing methods, such as hospital
discharge abstracts, referral letters and visit summaries among
healthcare professionals, are often delayed, incomplete or absent
(15). Incorporating Cloud-computing technology allows real-time
sharing of information, improves the quality of healthcare
delivery and facilitates advanced healthcare applications, including
the processing of large volumes of data (12).
Real-time information sharing that is powered by technology
enhances close collaboration among healthcare professionals and
can ensure a systematic view of patients’ illnesses, empower
healthcare professionals with various analytic tools to analyze
medical examination results, identify trends and patterns, and
compare the effectiveness of differing medical treatments. This will
 V. Baskaran et al. / Can J Diabetes 39 (2015) 200e203
not only significantly improve the accuracy of medical diagnoses
but will also drastically enhance the results of medical treatments.
New technology-based solutions, such as mobile platform and
Cloud-based computing, open up new vistas and complement
healthcare delivery by supporting the limited resources available to
the end users (16).
Cloud computing has the potential to help improve the quality
of healthcare delivery in many ways, including increased health-
care accessibility, reduced costs and minimized risks in managing
technologies. Healthcare professionals can provide diabetes care-
related services using Cloud computing with patients in remote
areas; patients with special needs (e.g. those aging or disabled)
could stay at home and receive care (17) and treatments (5). As
part of the collaboration strategy, patients with diabetes who are
in remote regions could communicate synchronously and asyn-
chronously with healthcare professionals concerning therapeutic
issues (18e21) such as diabetes.
Cloud computing offers advanced healthcare applications,
communication tools and hardware capable of processing a large
volume of data in various formats on a pay-by-use basis (22). Type 1
diabetes is commonly associated with comorbid conditions, such as
depression, hypothyroidism or celiac disease; in addition to these
conditions, longitudinal evaluation of the heights, weights and
eating disorders in children and adolescents adds an additional
layer of complexity to type 1 diabetes (23). Healthcare institutions
can utilize both advanced clinical software applications (e.g. health
records management) and nonclinical software applications to
provide comprehensive diabetes care to children and adolescents.
Cloud computing would enable a close collaboration among
diabetes-management professionals by supporting real-time in-
formation sharing such as the proposed solution. Creating an
electronic health record in the Cloud has been tested by many re-
searchers (23e25).
Although Cloud computing delivers several benefits to the
advancement of self-management of diabetes, Cloud-based solu-
tions are prone to privacy, security, portability and reliability issues
(23e25). There are technologies and protocols that specifically
address these privacy, security, portability and reliability issues.
These concerns can be addressed by the Cloud service providers
and medical professionals through various mechanisms, including
role-based access, network security mechanisms, data encryption,
digital signatures and access monitoring (25). The proposed solu-
tion will incorporate role-based access, network security mecha-
nisms, data encryption, digital signatures, and access monitoring by
both the teams and the patients concerned with type 1 diabetes.
Despite the fast growth and adoption of Cloud computing in
other countries (26,27), there is a lack of research into the adoption
of Cloud computing for healthcare delivery in Canada and the
potential challenges associated with its adoption in managing type
1 diabetes. This research describes a self-management application
for type 1 diabetes that is closely monitored by the type 1 diabetes
team and examines the adoption of a Cloud-computing software
application to make it economic, efficient, sustainable and acces-
sible by children and adolescents. Ontario healthcare has been
adopting tools and technologies that can alleviate the many chal-
lenges that are associated with the management of diabetes.
Patients diagnosed with type 1 diabetes are normally young adults
(28,29), and this generation of young adults tends to possess
smartphones that can be utilized by healthcare researchers to
further the research into the intersection of personal technology
and healthcare (30).
Methods
The current research proposes to create a health informatics
platform based on Cloud-computing technologies that offers an
201
integrated toolset that will keep track of type 1 diabetes manage-
ment, such as exercise, food, education and training, through an
interactive, multilanguage support application. In particular, the
platform contains 2 individual but interlinked components: stage 1,
fall detection; and stage 2, type 1 diabetes management.
Stage 1: Fall detection
Fall detection using wearable devices has been researched by
many researchers to create an efficient posture-recognition algo-
rithm to identify the posture of an individual (31,32). Accelerom-
eter and gyroscopes depend on the linear acceleration and angular
velocity to detect accurately the postures of individuals (32). Such
studies used the smartphone as a device to measure the linear
acceleration and angular velocity. Additionally, the devices depend
on complex software to classify the postures and their transitions,
especially falls (31,32). In our research, we intend to use the algo-
rithm proposed by Li et al (32) to create a client side for this soft-
ware that will reside as a mobile application (app) by using the
Cloud as the repository and sharing mechanism for training and
updating the posture-recognition algorithm, which compares
acceleration and rotational rate with set benchmarks (32) (option 1,
Figure 1). The app will enable the smartphone to be used as a
minimal computation device for identifying posture changes and,
in particular, falls.
In addition to the algorithm, this intelligent app progressively
responds to emergency situations. This occurs because devices and
applications are prone to false positives. To address this problem,
the responses to the emergency system are organized in 3 pro-
gressive stages. During phase 1 of the proposed app (Figure 1), the
app will try to communicate with the wearer to ascertain whether
the fall detected is a false-positive occurrence or not. If the user
acknowledges a false positive, the event is logged, and the algo-
rithm is reset and will continuously monitor the wearer (a patient
with type 1 diabetes). When the wearer fails to acknowledge the
detected fall, the algorithm will escalate the event to the next
phase. In the next phase (phase 2), a pre-identified family member
or friend, based on the person’s proximity, will be contacted
through an automated voice call to indicate that the wearer may be
having a hypoglycemic episode and may need immediate attention
(Figure 1).
 
t
Pðt; lÞ ¼ min ; 3 (1)
l
Most of the patients with type 1 diabetes are young adults, so
they may ignore or fail to acknowledge the automated message in
phase 1. Hence, a call from the pre-identified family members or
friends will enable the wearers to acknowledge the false fall
detection. If the pre-identified family members or friends cannot
communicate with the wearers, and the wearers have not
acknowledged the fall detection, the app will automatically escalate
the event to the final phase (phase 3). Phase 3 (Figure 1) is initiated
after a set time and automatically contacts emergency services at
911. The emergency contact, through an automated message that
provides the wearers’ (the patients with type 1 diabetes) medical
conditions and their global positioning system (GPS) locations to
the automated call for speedy dispatch of emergency personnel.
Once the app has entered the active phase 3, it does not switch off
its transmissions but sends continuous alerts concerning the loca-
tions of the wearers until the emergency personnel can locate the
patients with type 1 diabetes, administer initial care and reset the
app.
The complete stage 1 can be stated as an expression (1), where
the phase P is a function of the time since a fall event and the length
of time to reach a phase change. In this function, l is assumed to be
202 V. Baskaran et al. / Can J Diabetes 39 (2015) 200e203

Fall detecon
SaaS-based diabetes type 1
Disease management team
(Excercise, Food, Education, Training, and
Multi-language support)
Option 1 911
c all
e3
as
Ph EHR – canadian
call infostructure
2
Phase Family

smartphone with Fall detection Database

Accelerometer & algorithm update
Gyroscope connected server
app for fal detection
Firewall
Alert patient – phase 1

Wireless / WiFi

Option 2
Firewall
Diabetes web app
monitors diabetes
management
Mobile device
accessing type 1
diabetes app Cloud

Option 3
Clincial
Firewall stakeholders

ISP
Patient with type 1 diabetes
PC access type 1
diabetes app @ HOME
Type 1 diabetes management

Figure 1. Type 1 diabetes management: Architectural framework Software as a Service (SaaS), Electronic Health Record (EHR).

constant for all phase changes, i.e. the amount of time to change
from phase 0 to 1 is the same as the change from phase 1 to 2 and so
on; and
  
t adolescents to self-manage their type 1 conditions. Evidence sug-
Pðt; lÞ ¼ min ; 3
l gests that young children and adolescents have low adherence to
denotes the floor (truncate) function. P is the phase, t is the time
since fall detection, and l is the length of time to reach a phase
change in the same units as t.
Stage 2: Type 1 diabetes management
The key function of stage 2 is to provide an integrated, net-
worked and Cloud-based platform for all the stakeholders partici-
pating in the management of patients with type 1 diabetes. The
proposed research would also explore the application of a combi-
nation of information technology tools (e.g. mobile device, wireless
connectivity and Cloud computing) for effective type 1 diabetes
management (Figure 1). A Cloud-computing software application
that is accessible to mobile devices (e.g. mobile phones) would
monitor the patients, track food consumption and insulin intake,
alert the patients to adhere to the user-defined food-medicine-
exercise protocols generated by the diabetes management teams,
and inform the concerned authorities and stakeholders about the
patients’ conditions (option 2, Figure 1).
Through tailor-made settings that are identified during the ap-
plication’s installation stage, the patients would enable the app to
recognize, through user inputs, picture recognitions and locations
(such as restaurants), to make data capture easy and accurate.
Option 2 will be based on the app’s running on the mobile devices
or smartphones to record the calories consumed by the patients
with type 1 diabetes and the number of hours of exercise under-
taken by the patients. These details will be logged onto the diabetes
web server app on the Cloud and update the database.
This server-side web-based app will display the food-medicine-
exercise protocols and any deviations from the recommendations
made by the clinical stakeholders as alerts, on their mobile devices,
to the patients with type 1 diabetes, thus enabling the children or
(1)
strict regimes of dietary requirements, exercise and insulin intake
(23), so the proposed Cloud-based application will autonomously
warn patients to address the deviation recorded. When such de-
viations are not addressed, the information would be logged into
the Cloud-based servers, which initiate contact with the families
first; failing that, it will contact the multidisciplinary diabetes
management teams. This, in turn, minimizes the additional
responsibility forced on the healthcare professionals in the multi-
disciplinary diabetes management team.
This app can also be used as a gateway (option 3) to the
knowledge base through which patients with type 1 diabetes
(especially young patients) query and learn about diabetes disease-
related information in a user-friendly and multilanguage interface
to address the differing needs of the general population, including
new immigrants, which is an element unique to Ontario. The
material relevant to patients with type 1 diabetes would be initially
customized by the multidisciplinary diabetes management team,
which would consist of a member who is conversant with the
patients’ cultural needs. The flagged material will be seamlessly
assembled, customized and presented to the patients using the
web-based Smart Personalization Engine (33).
Option 3 is aimed at providing normal access for patients with
type 1 diabetes through a laptop or a desktop so that the patients
are kept abreast of information from the clinical stakeholders who
are part of the diabetes management team. Additionally, the
available information also reflects the information flow from the
electronic health record as part of the Canadian health infos-
tructure. All major interventions related to diabetes management
will also be communicated to the electronic health records. In
 V. Baskaran et al. / Can J Diabetes 39 (2015) 200e203
addition to the development and testing of the Cloud-computing
software application, future research would examine how type 1
diabetes management helps to reduce long-term complications in a
young population and investigate how tools, such as role-based
access, network security mechanisms, data encryption, digital sig-
natures, and access monitoring, can be employed effectively
without compromising privacy, security, confidentiality and reli-
ability issues.
Conclusion
Diabetes has become one of the more common chronic diseases
and thus places enormous burdens on the Canadian healthcare
system. To address the issue, this article presents a health
informatics-based, novel idea of using smartphone and Cloud-
computing technologies to monitor patients and assist patients in
managing the disease. This particular study, forthwith of research
ethics board approval, will design and implement the prototype
through the active participation of patients with type 1 diabetes
and healthcare professionals who are members of the Canadian
Diabetes Association. At the prototype developmental level, not all
patients at various socioeconomic levels will be taking part in the
testing and calibrating phases. During the later stages, patients
representing every socioeconomic status will be participating in
the research. The final outcomes of this proposed research will
include recommendations concerning how the Canadian Diabetes
Association can address the economic inequality among the chil-
dren and adolescents who have been diagnosed with type 1 dia-
betes by using federal and provincial funding support.
The research holds potential for a successful implementation
of a type 1 diabetes management tool that involves minimal
investment.
Acknowledgement
We acknowledge the participation of Dr. Michael Roty, Associate
Professor of Mathematics at Mercer University, for his contribution
to the equation in this article.
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