Service for the pseudonymization of electronic healthcare records based on ISO/EN 13606 for the secondary use of information

The availability of electronic health data favors scientific advance through the creation of repositories for secondary use. Data anonymization is a mandatory step to comply with current legislation. A service for the pseudonymization of electronic healthcare record (EHR) extracts aimed at facilitating the exchange of clinical information for secondary use in compliance with legislation on data protection is presented. According to ISO/TS 25237, pseudonymization is a particular type of anonymization. This tool performs the anonymizations by maintaining three quasi-identifiers (gender, date of birth and place of residence) with a degree of specification selected by the user. The developed system is based on the ISO/EN 13606 norm using its characteristics specifically favorable for anonymization. The service is made up of two independent modules: the demographic server and the pseudonymizing module. The demographic server supports the permanent storage of the demographic entities and the management of the identifiers. The pseudonymizing module anonymizes the ISO/EN 13606 extracts. The pseudonymizing process consists of four phases: the storage of the demographic information included in the extract, the substitution of the identifiers, the elimination of the demographic information of the extract and the elimination of key data in free-text fields. The described pseudonymizing system was used in three Telemedicine research projects with satisfactory results. A problem was detected with the type of data in a demographic data field and a proposal for modification was prepared for the group in charge of the drawing up and revision of the ISO/EN 13606 norm.

MAIA: an event-based modular architecture for intelligent agents

Online services are no longer isolated. The release of public APIs and technologies such as web hooks are allowing users and developers to access their information easily. Intelligent agents could use this information to provide a better user experience across services, connecting services with smart automatic. behaviours or actions. However, agent platforms are not prepared to easily add external sources such as web services, which hinders the usage of agents in the so-called Evented or Live Web. As a solution, this paper introduces an event-based architecture for agent systems, in accordance with the new tendencies in web programming. In particular, it is focused on personal agents that interact with several web services. With this architecture, called MAIA, connecting to new web services does not involve any modification in the platform.

Quality-optimization algorithm based on stochastic dynamic programming for MPEG DASH video streaming

In contrast to traditional push-based protocols, adaptive streaming techniques like Dynamic Adaptive Streaming over HTTP (DASH) fix attention on the client, who dynamically requests different-quality portions of the content to cope with a limited and variable bandwidth but aiming at maximizing the quality perceived by the user. Since DASH adaptation logic at the client is not covered by the standard, we propose a solution based on Stochastic Dynamic Programming (SDP) techniques to find the optimal request policies that guarantee the users' Quality of Experience (QoE). Our algorithm is evaluated in a simulated streaming session and is compared with other adaptation approaches. The results show that our proposal outperforms them in terms of QoE, requesting higher qualities on average.

An interactive web-based learning assistant for structural analysis of continuous beams

There are significant levels of concern about the relevance and the difficulty of learning some issues on Strength of Materials and Structural Analysis. Most students of Continuum Mechanics and Structural Analysis in Civil Engineering usually point out some key learning aspects as especially difficult for acquiring specific skills. These key concepts entail comprehension difficulties but ease access and applicability to structural analysis in more advanced subjects. Likewise, some elusive but basic structural concepts, such as flexibility, stiffness or influence lines, are paramount for developing further skills required for advanced structural design: tall buildings, arch-type structures as well as bridges. As new curricular itineraries are currently being implemented, it appears appropriate to devise a repository of interactive web-based applications for training in those basic concepts. That will hopefully train the student to understand the complexity of such concepts, to develop intuitive knowledge on actual structural response and to improve their preparation for exams. In this work, a web-based learning assistant system for influence lines on continuous beams is presented. It consists of a collection of interactive user-friendly applications accessible via Web. It is performed in both Spanish and English languages. Rather than a “black box” system, the procedure involves open interaction with the student, who can simulate and virtually envisage the structural response. Thus, the student is enabled to set the geometric, topologic and mechanic layout of a continuous beam and to change or shift the loading and the support conditions. Simultaneously, the changes in the beam response prompt on the screen, so that the effects of the several issues involved in structural analysis become apparent. The system is performed through a set of web pages which encompasses interactive exercises and problems, written in JavaScript under JQuery and DyGraphs frameworks, given that their efficiency and graphic capabilities are renowned. Students can freely boost their self-study on this subject in order to face their exams more confidently. Besides, this collection is expected to be added to the "Virtual Lab of Continuum Mechanics" of the UPM, launched in 2013 (http://serviciosgate.upm.es/laboratoriosvirtuales/laboratorios/medios-continuos-en-construcci%C3%B3n)

Crowdsourcing based subjective quality assessment of adaptive video streaming

In order to cater for user's quality of experience (QoE) requirements, HTTP adaptive streaming (HAS) based solutions of video services have become popular recently. User QoE feedback can be instrumental in improving the capabilities of such services. Perceptual quality experiments that involve humans are considered to be the most valid method of the assessment of QoE. Besides lab-based subjective experiments, crowdsourcing based subjective assessment of video quality is gaining popularity as an alternative method. This paper presents insights into a study that investigates perceptual preferences of various adaptive video streaming scenarios through crowdsourcing based subjective quality assessment.

Emergency management in the highways of the future. A performance-based multilayered ITS architecture design proposal

Emergency management is one of the key aspects within the day-to-day operation procedures in a highway. Efficiency in the overall response in case of an incident is paramount in reducing the consequences of any incident. However, the approach of highway operators to the issue of incident management is still usually far from a systematic, standardized way. This paper attempts to address the issue and provide several hints on why this happens, and a proposal on how the situation could be overcome. An introduction to a performance based approach to a general system specification will be described, and then applied to a particular road emergency management task. A real testbed has been implemented to show the validity of the proposed approach. Ad-hoc sensors (one camera and one laser scanner) were efficiently deployed to acquire data, and advanced fusion techniques applied at the processing stage to reach the specific user requirements in terms of functionality, flexibility and accuracy.

A Ground-Truth Video Dataset for the Development and Evaluation of Vision-based Sense-and-Avoid systems

The importance of vision-based systems for Sense-and-Avoid is increasing nowadays as remotely piloted and autonomous UAVs become part of the non-segregated airspace. The development and evaluation of these systems demand flight scenario images which are expensive and risky to obtain. Currently Augmented Reality techniques allow the compositing of real flight scenario images with 3D aircraft models to produce useful realistic images for system development and benchmarking purposes at a much lower cost and risk. With the techniques presented in this paper, 3D aircraft models are positioned firstly in a simulated 3D scene with controlled illumination and rendering parameters. Realistic simulated images are then obtained using an image processing algorithm which fuses the images obtained from the 3D scene with images from real UAV flights taking into account on board camera vibrations. Since the intruder and camera poses are user-defined, ground truth data is available. These ground truth annotations allow to develop and quantitatively evaluate aircraft detection and tracking algorithms. This paper presents the software developed to create a public dataset of 24 videos together with their annotations and some tracking application results.

Software architecture implementation based on OpenSim

One of the objectives of the European Higher Education Area is the promotion of collaborative and informal learning through the implementation of educational practices. 3D virtual environments become an ideal space for such activities. On the other hand, the problem of financing in Spanish universities has led to the search for new ways to optimize available resources. The Technical University of Madrid requires the use of laboratories which due to their dangerousness, duration or control of the developed processes are difficult to perform in real life. For this reason, we have developed several 3D laboratories in virtual environment. The laboratories are built on open source platform OpenSim. In this paper it is exposed the use of the OpenSim platform for these new teaching experiences and the new design of the software architecture. This architecture requires the adaptation of the platform to the needs of the users and the different laboratories of our University. We will explain the structure of the implemented architecture and the process of creating and configuring it. The proposed architecture is decentralized, each laboratory is housed in different an educational center. The architecture adds several services, among others, the creation and management of users automated, communication between external services and platforms in different program languages. Therefore, we achieve improving the user experience and rising the functionalities of laboratories.

Fault management techniques for systems with SRAM-based FPGAs

Las Field-Programmable Gate Arrays (FPGAs) SRAM se construyen sobre una memoria de configuración de tecnología RAM Estática (SRAM). Presentan múltiples características que las hacen muy interesantes para diseñar sistemas empotrados complejos. En primer lugar presentan un coste no-recurrente de ingeniería (NRE) bajo, ya que los elementos lógicos y de enrutado están pre-implementados (el diseño de usuario define su conexionado). También, a diferencia de otras tecnologías de FPGA, pueden ser reconfiguradas (incluso en campo) un número ilimitado de veces. Es más, las FPGAs SRAM de Xilinx soportan Reconfiguración Parcial Dinámica (DPR), la cual permite reconfigurar la FPGA sin interrumpir la aplicación. Finalmente, presentan una alta densidad de lógica, una alta capacidad de procesamiento y un rico juego de macro-bloques. Sin embargo, un inconveniente de esta tecnología es su susceptibilidad a la radiación ionizante, la cual aumenta con el grado de integración (geometrías más pequeñas, menores tensiones y mayores frecuencias). Esta es una precupación de primer nivel para aplicaciones en entornos altamente radiativos y con requisitos de alta confiabilidad. Este fenómeno conlleva una degradación a largo plazo y también puede inducir fallos instantáneos, los cuales pueden ser reversibles o producir daños irreversibles. En las FPGAs SRAM, los fallos inducidos por radiación pueden aparecer en en dos capas de arquitectura diferentes, que están físicamente superpuestas en el dado de silicio. La Capa de Aplicación (o A-Layer) contiene el hardware definido por el usuario, y la Capa de Configuración contiene la memoria de configuración y la circuitería de soporte. Los fallos en cualquiera de estas capas pueden hacer fracasar el sistema, lo cual puede ser ás o menos tolerable dependiendo de los requisitos de confiabilidad del sistema. En el caso general, estos fallos deben gestionados de alguna manera. Esta tesis trata sobre la gestión de fallos en FPGAs SRAM a nivel de sistema, en el contexto de sistemas empotrados autónomos y confiables operando en un entorno radiativo. La tesis se centra principalmente en aplicaciones espaciales, pero los mismos principios pueden aplicarse a aplicaciones terrenas. Las principales diferencias entre ambas son el nivel de radiación y la posibilidad de mantenimiento. Las diferentes técnicas para la gestión de fallos en A-Layer y C-Layer son clasificados, y sus implicaciones en la confiabilidad del sistema son analizados. Se proponen varias arquitecturas tanto para Gestores de Fallos de una capa como de doble-capa. Para estos últimos se propone una arquitectura novedosa, flexible y versátil. Gestiona las dos capas concurrentemente de manera coordinada, y permite equilibrar el nivel de redundancia y la confiabilidad. Con el objeto de validar técnicas de gestión de fallos dinámicas, se desarrollan dos diferentes soluciones. La primera es un entorno de simulación para Gestores de Fallos de C-Layer, basado en SystemC como lenguaje de modelado y como simulador basado en eventos. Este entorno y su metodología asociada permite explorar el espacio de diseño del Gestor de Fallos, desacoplando su diseño del desarrollo de la FPGA objetivo. El entorno incluye modelos tanto para la C-Layer de la FPGA como para el Gestor de Fallos, los cuales pueden interactuar a diferentes niveles de abstracción (a nivel de configuration frames y a nivel físico JTAG o SelectMAP). El entorno es configurable, escalable y versátil, e incluye capacidades de inyección de fallos. Los resultados de simulación para algunos escenarios son presentados y comentados. La segunda es una plataforma de validación para Gestores de Fallos de FPGAs Xilinx Virtex. La plataforma hardware aloja tres Módulos de FPGA Xilinx Virtex-4 FX12 y dos Módulos de Unidad de Microcontrolador (MCUs) de 32-bits de propósito general. Los Módulos MCU permiten prototipar Gestores de Fallos de C-Layer y A-Layer basados en software. Cada Módulo FPGA implementa un enlace de A-Layer Ethernet (a través de un switch Ethernet) con uno de los Módulos MCU, y un enlace de C-Layer JTAG con el otro. Además, ambos Módulos MCU intercambian comandos y datos a través de un enlace interno tipo UART. Al igual que para el entorno de simulación, se incluyen capacidades de inyección de fallos. Los resultados de pruebas para algunos escenarios son también presentados y comentados. En resumen, esta tesis cubre el proceso completo desde la descripción de los fallos FPGAs SRAM inducidos por radiación, pasando por la identificación y clasificación de técnicas de gestión de fallos, y por la propuesta de arquitecturas de Gestores de Fallos, para finalmente validarlas por simulación y pruebas. El trabajo futuro está relacionado sobre todo con la implementación de Gestores de Fallos de Sistema endurecidos para radiación. ABSTRACT SRAM-based Field-Programmable Gate Arrays (FPGAs) are built on Static RAM (SRAM) technology configuration memory. They present a number of features that make them very convenient for building complex embedded systems. First of all, they benefit from low Non-Recurrent Engineering (NRE) costs, as the logic and routing elements are pre-implemented (user design defines their connection). Also, as opposed to other FPGA technologies, they can be reconfigured (even in the field) an unlimited number of times. Moreover, Xilinx SRAM-based FPGAs feature Dynamic Partial Reconfiguration (DPR), which allows to partially reconfigure the FPGA without disrupting de application. Finally, they feature a high logic density, high processing capability and a rich set of hard macros. However, one limitation of this technology is its susceptibility to ionizing radiation, which increases with technology scaling (smaller geometries, lower voltages and higher frequencies). This is a first order concern for applications in harsh radiation environments and requiring high dependability. Ionizing radiation leads to long term degradation as well as instantaneous faults, which can in turn be reversible or produce irreversible damage. In SRAM-based FPGAs, radiation-induced faults can appear at two architectural layers, which are physically overlaid on the silicon die. The Application Layer (or A-Layer) contains the user-defined hardware, and the Configuration Layer (or C-Layer) contains the (volatile) configuration memory and its support circuitry. Faults at either layers can imply a system failure, which may be more ore less tolerated depending on the dependability requirements. In the general case, such faults must be managed in some way. This thesis is about managing SRAM-based FPGA faults at system level, in the context of autonomous and dependable embedded systems operating in a radiative environment. The focus is mainly on space applications, but the same principles can be applied to ground applications. The main differences between them are the radiation level and the possibility for maintenance. The different techniques for A-Layer and C-Layer fault management are classified and their implications in system dependability are assessed. Several architectures are proposed, both for single-layer and dual-layer Fault Managers. For the latter, a novel, flexible and versatile architecture is proposed. It manages both layers concurrently in a coordinated way, and allows balancing redundancy level and dependability. For the purpose of validating dynamic fault management techniques, two different solutions are developed. The first one is a simulation framework for C-Layer Fault Managers, based on SystemC as modeling language and event-driven simulator. This framework and its associated methodology allows exploring the Fault Manager design space, decoupling its design from the target FPGA development. The framework includes models for both the FPGA C-Layer and for the Fault Manager, which can interact at different abstraction levels (at configuration frame level and at JTAG or SelectMAP physical level). The framework is configurable, scalable and versatile, and includes fault injection capabilities. Simulation results for some scenarios are presented and discussed. The second one is a validation platform for Xilinx Virtex FPGA Fault Managers. The platform hosts three Xilinx Virtex-4 FX12 FPGA Modules and two general-purpose 32-bit Microcontroller Unit (MCU) Modules. The MCU Modules allow prototyping software-based CLayer and A-Layer Fault Managers. Each FPGA Module implements one A-Layer Ethernet link (through an Ethernet switch) with one of the MCU Modules, and one C-Layer JTAG link with the other. In addition, both MCU Modules exchange commands and data over an internal UART link. Similarly to the simulation framework, fault injection capabilities are implemented. Test results for some scenarios are also presented and discussed. In summary, this thesis covers the whole process from describing the problem of radiationinduced faults in SRAM-based FPGAs, then identifying and classifying fault management techniques, then proposing Fault Manager architectures and finally validating them by simulation and test. The proposed future work is mainly related to the implementation of radiation-hardened System Fault Managers.

Optimal Piecewise Linear Function Approximation for GPU-based Applications

Many computer vision and human-computer interaction applications developed in recent years need evaluating complex and continuous mathematical functions as an essential step toward proper operation. However, rigorous evaluation of this kind of functions often implies a very high computational cost, unacceptable in real-time applications. To alleviate this problem, functions are commonly approximated by simpler piecewise-polynomial representations. Following this idea, we propose a novel, efficient, and practical technique to evaluate complex and continuous functions using a nearly optimal design of two types of piecewise linear approximations in the case of a large budget of evaluation subintervals. To this end, we develop a thorough error analysis that yields asymptotically tight bounds to accurately quantify the approximation performance of both representations. It provides an improvement upon previous error estimates and allows the user to control the trade-off between the approximation error and the number of evaluation subintervals. To guarantee real-time operation, the method is suitable for, but not limited to, an efficient implementation in modern Graphics Processing Units (GPUs), where it outperforms previous alternative approaches by exploiting the fixed-function interpolation routines present in their texture units. The proposed technique is a perfect match for any application requiring the evaluation of continuous functions, we have measured in detail its quality and efficiency on several functions, and, in particular, the Gaussian function because it is extensively used in many areas of computer vision and cybernetics, and it is expensive to evaluate.

Non-invasive user monitoring in daily tasks for cognitive rehabilitation

El uso de técnicas para la monitorización del movimiento humano generalmente permite a los investigadores analizar la cinemática y especialmente las capacidades motoras en aquellas actividades de la vida cotidiana que persiguen un objetivo concreto como pueden ser la preparación de bebidas y comida, e incluso en tareas de aseo. Adicionalmente, la evaluación del movimiento y el comportamiento humanos en el campo de la rehabilitación cognitiva es esencial para profundizar en las dificultades que algunas personas encuentran en la ejecución de actividades diarias después de accidentes cerebro-vasculares. Estas dificultades están principalmente asociadas a la realización de pasos secuenciales y al reconocimiento del uso de herramientas y objetos. La interpretación de los datos sobre la actitud de este tipo de pacientes para reconocer y determinar el nivel de éxito en la ejecución de las acciones, y para ampliar el conocimiento en las enfermedades cerebrales, sus consecuencias y severidad, depende totalmente de los dispositivos usados para la captura de esos datos y de la calidad de los mismos. Más aún, existe una necesidad real de mejorar las técnicas actuales de rehabilitación cognitiva contribuyendo al diseño de sistemas automáticos para crear una especie de terapeuta virtual que asegure una vida más independiente de estos pacientes y reduzca la carga de trabajo de los terapeutas. Con este objetivo, el uso de sensores y dispositivos para obtener datos en tiempo real de la ejecución y estado de la tarea de rehabilitación es esencial para también contribuir al diseño y entrenamiento de futuros algoritmos que pudieran reconocer errores automáticamente para informar al paciente acerca de ellos mediante distintos tipos de pistas como pueden ser imágenes, mensajes auditivos o incluso videos. La tecnología y soluciones existentes en este campo no ofrecen una manera totalmente robusta y efectiva para obtener datos en tiempo real, por un lado, porque pueden influir en el movimiento del propio paciente en caso de las plataformas basadas en el uso de marcadores que necesitan sensores pegados en la piel; y por otro lado, debido a la complejidad o alto coste de implantación lo que hace difícil pensar en la idea de instalar un sistema en el hospital o incluso en la casa del paciente. Esta tesis presenta la investigación realizada en el campo de la monitorización del movimiento de pacientes para proporcionar un paso adelante en términos de detección, seguimiento y reconocimiento del comportamiento de manos, gestos y cara mediante una manera no invasiva la cual puede mejorar la técnicas actuales de rehabilitación cognitiva para la adquisición en tiempo real de datos sobre el comportamiento del paciente y la ejecución de la tarea. Para entender la importancia del marco de esta tesis, inicialmente se presenta un resumen de las principales enfermedades cognitivas y se introducen las consecuencias que tienen en la ejecución de tareas de la vida diaria. Más aún, se investiga sobre las metodologías actuales de rehabilitación cognitiva. Teniendo en cuenta que las manos son la principal parte del cuerpo para la ejecución de tareas manuales de la vida cotidiana, también se resumen las tecnologías existentes para la captura de movimiento de manos. Una de las principales contribuciones de esta tesis está relacionada con el diseño y evaluación de una solución no invasiva para detectar y seguir las manos durante la ejecución de tareas manuales de la vida cotidiana que a su vez involucran la manipulación de objetos. Esta solución la cual no necesita marcadores adicionales y está basada en una cámara de profundidad de bajo coste, es robusta, precisa y fácil de instalar. Otra contribución presentada se centra en el reconocimiento de gestos para detectar el agarre de objetos basado en un sensor infrarrojo de última generación, y también complementado con una cámara de profundidad. Esta nueva técnica, y también no invasiva, sincroniza ambos sensores para seguir objetos específicos además de reconocer eventos concretos relacionados con tareas de aseo. Más aún, se realiza una evaluación preliminar del reconocimiento de expresiones faciales para analizar si es adecuado para el reconocimiento del estado de ánimo durante la tarea. Por su parte, todos los componentes y algoritmos desarrollados son integrados en un prototipo simple para ser usado como plataforma de monitorización. Se realiza una evaluación técnica del funcionamiento de cada dispositivo para analizar si es adecuada para adquirir datos en tiempo real durante la ejecución de tareas cotidianas reales. Finalmente, se estudia la interacción con pacientes reales para obtener información del nivel de usabilidad del prototipo. Dicha información es esencial y útil para considerar una rehabilitación cognitiva basada en la idea de instalación del sistema en la propia casa del paciente al igual que en el hospital correspondiente. ABSTRACT The use of human motion monitoring techniques usually let researchers to analyse kinematics, especially in motor strategies for goal-oriented activities of daily living, such as the preparation of drinks and food, and even grooming tasks. Additionally, the evaluation of human movements and behaviour in the field of cognitive rehabilitation is essential to deep into the difficulties some people find in common activities after stroke. This difficulties are mainly associated with sequence actions and the recognition of tools usage. The interpretation of attitude data of this kind of patients in order to recognize and determine the level of success of the execution of actions, and to broaden the knowledge in brain diseases, consequences and severity, depends totally on the devices used for the capture of that data and the quality of it. Moreover, there is a real need of improving the current cognitive rehabilitation techniques by contributing to the design of automatic systems to create a kind of virtual therapist for the improvement of the independent life of these stroke patients and to reduce the workload of the occupational therapists currently in charge of them. For this purpose, the use of sensors and devices to obtain real time data of the execution and state of the rehabilitation task is essential to also contribute to the design and training of future smart algorithms which may recognise errors to automatically provide multimodal feedback through different types of cues such as still images, auditory messages or even videos. The technology and solutions currently adopted in the field don't offer a totally robust and effective way for obtaining real time data, on the one hand, because they may influence the patient's movement in case of marker-based platforms which need sensors attached to the skin; and on the other hand, because of the complexity or high cost of implementation, which make difficult the idea of installing a system at the hospital or even patient's home. This thesis presents the research done in the field of user monitoring to provide a step forward in terms of detection, tracking and recognition of hand movements, gestures and face via a non-invasive way which could improve current techniques for cognitive rehabilitation for real time data acquisition of patient's behaviour and execution of the task. In order to understand the importance of the scope of the thesis, initially, a summary of the main cognitive diseases that require for rehabilitation and an introduction of the consequences on the execution of daily tasks are presented. Moreover, research is done about the actual methodology to provide cognitive rehabilitation. Considering that the main body members involved in the completion of a handmade daily task are the hands, the current technologies for human hands movements capture are also highlighted. One of the main contributions of this thesis is related to the design and evaluation of a non-invasive approach to detect and track user's hands during the execution of handmade activities of daily living which involve the manipulation of objects. This approach does not need the inclusion of any additional markers. In addition, it is only based on a low-cost depth camera, it is robust, accurate and easy to install. Another contribution presented is focused on the hand gesture recognition for detecting object grasping based on a brand new infrared sensor, and also complemented with a depth camera. This new, and also non-invasive, solution which synchronizes both sensors to track specific tools as well as recognize specific events related to grooming is evaluated. Moreover, a preliminary assessment of the recognition of facial expressions is carried out to analyse if it is adequate for recognizing mood during the execution of task. Meanwhile, all the corresponding hardware and software developed are integrated in a simple prototype with the purpose of being used as a platform for monitoring the execution of the rehabilitation task. Technical evaluation of the performance of each device is carried out in order to analyze its suitability to acquire real time data during the execution of real daily tasks. Finally, a kind of healthcare evaluation is also presented to obtain feedback about the usability of the system proposed paying special attention to the interaction with real users and stroke patients. This feedback is quite useful to consider the idea of a home-based cognitive rehabilitation as well as a possible hospital installation of the prototype.

Quality cost in bus operations based on activity-based costing

The study of service quality and its implication for transport contracts has several approaches in research and practical applications, where the main emphasis is the consideration of quality from the user's point of view, thus obtaining a customer satisfaction index as a measurement of the overall quality with no further implications for service providers. The main aim of this paper is to estimate the real economic impact of improving quality attributes for a bus operator. An application of the activity-based costing methodology is developed for a bus contract in Madrid, using quality data from surveys together with economic and performance information, and focusing on headway as a quality variable. Results show the consistency and practicality of this methodology, overcoming simplifications from traditional procedures. This method is a powerful tool in quality-based contracting as well as for effective investment in transport quality under poverty funding constraints

New QR Survey Methodologies to Analyze User Perception of Service Quality in Public Transport: The Experience of Madrid

Customer Satisfaction Surveys (CSS) have become an important tool for public transport planners, as improvements in the perceived quality of service lead to greater use of public transport and lower traffic pollution. Until now, Intelligent Transportation System (ITS) enhancements in public transport have traditionally included fleet management systems based on Automatic Vehicle Location (AVL) technologies, which can be used to optimize routing and scheduling, and to feed real-time information into passenger information channels. However, surveys of public transport users could also benefit from the new information technologies. As most customers carry their smartphones when traveling, Quick Response (QR) codes open up the possibility of conducting these surveys at a lower cost.This paper contributes to the limited existing literature by developing the analysis of QR codes applied to CSS in public transport and highlighting their importance in reducing the cost of data collection and processing. The added value of this research is that it provides the first assessment of a real case study in Madrid (Spain) using QR codes for this purpose. This pilot experience was part of a research project analyzing bus service quality in the same case study, so the QR code survey (155 valid questionnaires) was validated using a conventional face-to-face survey (520 valid questionnaires). The results show clearly that, after overcoming a few teething troubles, this QR code application will ultimately provide transport management with a useful tool to reduce survey costs

An ICT-based closed-loop model to improve care for heart failure patients

Durante las últimas décadas se ha producido un fenómeno global de envejecimiento en la población. Esta tendencia se puede observar prácticamente en todos los países del mundo y se debe principalmente a los avances en la medicina, y a los descensos en las tasas de fertilidad y mortalidad. El envejecimiento de la población tiene un gran impacto en la salud de los ciudadanos, y a menudo es la causa de aparición de enfermedades crónicas. Este tipo de enfermedades supone una amenaza y una carga importantes para la sociedad, especialmente en aspectos como la mortalidad o los gastos en los sistemas sanitarios. Entre las enfermedades cardiovasculares, la insuficiencia cardíaca es probablemente la condición con mayor prevalencia y afecta a 23-26 millones de personas en todo el mundo. Normalmente, la insuficiencia cardíaca presenta un mal pronóstico y una tasa de supervivencia bajas, en algunos casos peores que algún tipo de cáncer. Además, suele ser la causa de hospitalizaciones frecuentes y es una de las enfermedades más costosas para los sistemas sanitarios. La tendencia al envejecimiento de la población y la creciente incidencia de las enfermedades crónicas están llevando a una situación en la que los sistemas de salud no son capaces de hacer frente a la demanda de la sociedad. Los servicios de salud existentes tendrán que adaptarse para ser efectivos y sostenibles en el futuro. Es necesario identificar nuevos paradigmas de cuidado de pacientes, así como mecanismos para la provisión de servicios que ayuden a transformar estos sistemas sanitarios. En este contexto, esta tesis se plantea la búsqueda de soluciones, basadas en las Tecnologías de la Información y la Comunicación (TIC), que contribuyan a realizar la transformación en los sistemas sanitarios. En concreto, la tesis se centra en abordar los problemas de una de las enfermedades con mayor impacto en estos sistemas: la insuficiencia cardíaca. Las siguientes hipótesis constituyen la base para la realización de este trabajo de investigación: 1. Es posible definir un modelo basado en el paradigma de lazo cerrado y herramientas TIC que formalice el diseño de mejores servicios para pacientes con insuficiencia cardíaca. 2. El modelo de lazo cerrado definido se puede utilizar para definir un servicio real que ayude a gestionar la insuficiencia cardíaca crónica. 3. La introducción, la adopción y el uso de un servicio basado en el modelo definido se traducirá en mejoras en el estado de salud de los pacientes que sufren insuficiencia cardíaca. a. La utilización de un sistema basado en el modelo de lazo cerrado definido mejorará la experiencia del usuario de los pacientes. La definición del modelo planteado se ha basado en el estándar ISO / EN 13940- Sistema de conceptos para dar soporte a la continuidad de la asistencia. Comprende un conjunto de conceptos, procesos, flujos de trabajo, y servicios como componentes principales, y representa una formalización de los servicios para los pacientes con insuficiencia cardíaca. Para evaluar el modelo definido se ha definido un servicio real basado en el mismo, además de la implementación de un sistema de apoyo a dicho servicio. El diseño e implementación de dicho sistema se realizó siguiendo la metodología de Diseño Orientado a Objetivos. El objetivo de la evaluación consistía en investigar el efecto que tiene un servicio basado en el modelo de lazo cerrado sobre el estado de salud de los pacientes con insuficiencia cardíaca. La evaluación se realizó en el marco de un estudio clínico observacional. El análisis de los resultados ha comprendido métodos de análisis cuantitativos y cualitativos. El análisis cuantitativo se ha centrado en determinar el estado de salud de los pacientes en base a datos objetivos (obtenidos en pruebas de laboratorio o exámenes médicos). Para realizar este análisis se definieron dos índices específicos: el índice de estabilidad y el índice de la evolución del estado de salud. El análisis cualitativo ha evaluado la autopercepción del estado de salud de los pacientes en términos de calidad de vida, auto-cuidado, el conocimiento, la ansiedad y la depresión, así como niveles de conocimiento. Se ha basado en los datos recogidos mediante varios cuestionarios o instrumentos estándar (i.e. EQ-5D, la Escala de Ansiedad y Depresión (HADS), el Cuestionario de Cardiomiopatía de Kansas City (KCCQ), la Escala Holandesa de Conocimiento de Insuficiencia Cardíaca (DHFKS), y la Escala Europea de Autocuidado en Insuficiencia Cardíaca (EHFScBS), así como cuestionarios dedicados no estandarizados de experiencia de usuario. Los resultados obtenidos en ambos análisis, cuantitativo y cualitativo, se compararon con el fin de evaluar la correlación entre el estado de salud objetivo y subjetivo de los pacientes. Los resultados de la validación demostraron que el modelo propuesto tiene efectos positivos en el cuidado de los pacientes con insuficiencia cardíaca y contribuye a mejorar su estado de salud. Asimismo, ratificaron al modelo como instrumento válido para la definición de servicios mejorados para la gestión de esta enfermedad. ABSTRACT During the last decades we have witnessed a global aging phenomenon in the population. This can be observed in practically every country in the world, and it is mainly caused by the advances in medicine, and the decrease of mortality and fertility rates. Population aging has an important impact on citizens’ health and it is often the cause for chronic diseases, which constitute global burden and threat to the society in terms of mortality and healthcare expenditure. Among chronic diseases, Chronic Heart Failure (CHF) or Heart Failure (HF) is probably the one with highest prevalence, affecting between 23 and 26 million people worldwide. Heart failure is a chronic, long-term and serious condition with very poor prognosis and worse survival rates than some type of cancers. Additionally, it is often the cause of frequent hospitalizations and one of the most expensive conditions for the healthcare systems. The aging trends in the population and the increasing incidence of chronic diseases are leading to a situation where healthcare systems are not able to cope with the society demand. Current healthcare services will have to be adapted and redefined in order to be effective and sustainable in the future. There is a need to find new paradigms for patients’ care, and to identify new mechanisms for services’ provision that help to transform the healthcare systems. In this context, this thesis aims to explore new solutions, based on ICT, that contribute to achieve the needed transformation within the healthcare systems. In particular, it focuses on addressing the problems of one of the diseases with higher impact within these systems: Heart Failure. The following hypotheses represent the basis to the elaboration of this research: 1. It is possible to define a model based on a closed-loop paradigm and ICT tools that formalises the design of enhanced healthcare services for chronic heart failure patients. 2. The described closed-loop model can be exemplified in a real service that supports the management of chronic heart failure disease. 3. The introduction, adoption and use of a service based on the outlined model will result in improvements in the health status of patients suffering heart failure. 4. The user experience of patients when utilizing a system based on the defined closed-loop model will be enhanced. The definition of the closed-loop model for health care support of heart failure patients have been based on the standard ISO/EN 13940 System of concepts to support continuity of care. It includes a set of concept, processes and workflows, and services as main components, and it represent a formalization of services for heart failure patients. In order to be validated, the proposed closed-loop model has been instantiated into a real service and a supporting IT system. The design and implementation of the system followed the user centred design methodology Goal Oriented Design. The validation, that included an observational clinical study, aimed to investigate the effect that a service based on the closed-loop model had on heart failure patients’ health status. The analysis of results comprised quantitative and qualitative analysis methods. The quantitative analysis was focused on determining the health status of patients based on objective data (obtained in lab tests or physical examinations). Two specific indexes where defined and considered in this analysis: the stability index and the health status evolution index. The qualitative analysis assessed the self-perception of patients’ health status in terms of quality of life, self-care, knowledge, anxiety and depression, as well as knowledge levels. It was based on the data gathered through several standard instruments (i.e. EQ-5D, the Hospital Anxiety and Depression Scale, the Kansas City Cardiomyopathy Questionnaire, the Dutch Heart Failure Knowledge Scale, and the European Heart Failure Self-care Behaviour Scale) as well as dedicated non-standardized user experience questionnaires. The results obtained in both analyses, quantitative and qualitative, were compared in order to assess the correlation between the objective and subjective health status of patients. The results of the validation showed that the proposed model contributed to improve the health status of the patients and had a positive effect on the patients’ care. It also proved that the model is a valid instrument for designing enhanced healthcare services for heart failure patients.

A technological framework based on automatic messaging for improving adherence of diabetic patients

En todo el mundo se ha observado un crecimiento exponencial en la incidencia de enfermedades crónicas como la hipertensión y enfermedades cardiovasculares y respiratorias, así como la diabetes mellitus, que causa un número de muertes cada vez mayor en todo el mundo (Beaglehole et al., 2008). En concreto, la prevalencia de diabetes mellitus (DM) está aumentando de manera considerable en todas las edades y representa un serio problema de salud mundial. La diabetes fue la responsable directa de 1,5 millones de muertes en 2012 y 89 millones de años de vida ajustados por discapacidad (AVAD) (OMS, 2014). Uno de los principales dilemas que suelen asociarse a la gestión de EC es la adherencia de los pacientes a los tratamientos, que representa un aspecto multifactorial que necesita asistencia en lo relativo a: educación, autogestión, interacción entre los pacientes y cuidadores y compromiso de los pacientes. Medir la adherencia del tratamiento es complicado y, aunque se ha hablado ampliamente de ello, aún no hay soluciones “de oro” (Reviews, 2002). El compromiso de los pacientes, a través de la participación, colaboración, negociación y a veces del compromiso firme, aumentan las oportunidades para una terapia óptima en la que los pacientes se responsabilizan de su parte en la ecuación de adherencia. Comprometer e involucrar a los pacientes diabéticos en las decisiones de su tratamiento, junto con expertos profesionales, puede ayudar a favorecer un enfoque centrado en el paciente hacia la atención a la diabetes (Martin et al., 2005). La motivación y atribución de poder de los pacientes son quizás los dos factores interventores más relevantes que afectan directamente a la autogestión de la atención a la diabetes. Se ha demostrado que estos dos factores desempeñan un papel fundamental en la adherencia a la prescripción, así como en el fomento exitoso de un estilo de vida sana y otros cambios de conducta (Heneghan et al., 2013). Un plan de educación personalizada es indispensable para proporcionarle al paciente las herramientas adecuadas que necesita para la autogestión efectiva de la enfermedad (El-Gayar et al. 2013). La comunicación efectiva es fundamental para proporcionar una atención centrada en el paciente puesto que influye en las conductas y actitudes hacia un problema de salud ((Frampton et al. 2008). En este sentido, la interactividad, la frecuencia, la temporalización y la adaptación de los mensajes de texto pueden promover la adherencia a un régimen de medicación. Como consecuencia, adaptar los mensajes de texto a los pacientes puede resultar ser una manera de hacer que las sugerencias y la información sean más relevantes y efectivas (Nundy et al. 2013). En este contexto, las tecnologías móviles en el ámbito de la salud (mHealth) están desempeñando un papel importante al conectar con pacientes para mejorar la adherencia a medicamentos recetados (Krishna et al., 2009). La adaptación de los mensajes de texto específicos de diabetes sigue siendo un área de oportunidad para mejorar la adherencia a la medicación y ofrecer motivación a adultos con diabetes. Sin embargo, se necesita más investigación para entender totalmente su eficacia. Los consejos de texto personalizados han demostrado causar un impacto positivo en la atribución de poder a los pacientes, su autogestión y su adherencia a la prescripción (Gatwood et al., 2014). mHealth se puede utilizar para ofrecer programas de asistencia de autogestión a los pacientes con diabetes y, al mismo tiempo, superar las dificultades técnicas y financieras que supone el tratamiento de la diabetes (Free at al., 2013). El objetivo principal de este trabajo de investigación es demostrar que un marco tecnológico basado en las teorías de cambios de conducta, aplicado al campo de la mHealth, permite una mejora de la adherencia al tratamiento en pacientes diabéticos. Como método de definición de una solución tecnológica, se han adoptado un conjunto de diferentes técnicas de conducta validadas denominado marco de compromiso de retroacción conductual (EBF, por sus siglas en inglés) para formular los mensajes, guiar el contenido y evaluar los resultados. Los estudios incorporan elementos del modelo transteórico (TTM, por sus siglas en inglés), la teoría de la fijación de objetivos (GST, por sus siglas en inglés) y los principios de comunicación sanitaria persuasiva y eficaz. Como concepto general, el modelo TTM ayuda a los pacientes a progresar a su próxima fase de conducta a través de mensajes de texto motivados específicos y permite que el médico identifique la fase actual y adapte sus estrategias individualmente. Además, se adoptan las directrices del TTM para fijar objetivos personalizados a un nivel apropiado a la fase de cambio del paciente. La GST encierra normas que van a ponerse en práctica para promover la intervención educativa y objetivos de pérdida de peso. Finalmente, los principios de comunicación sanitaria persuasiva y eficaz aplicados a la aparición de los mensajes se han puesto en marcha para aumentar la efectividad. El EBF tiene como objetivo ayudar a los pacientes a mejorar su adherencia a la prescripción y encaminarlos a una mejora general en la autogestión de la diabetes mediante mensajes de texto personalizados denominados mensajes de retroacción automáticos (AFM, por sus siglas en inglés). Después de una primera revisión del perfil, consistente en identificar características significativas del paciente basadas en las necesidades de tratamiento, actitudes y conductas de atención sanitaria, el sistema elige los AFM personalizados, los aprueba el médico y al final se transfieren a la interfaz del paciente. Durante el tratamiento, el usuario recopila los datos en dispositivos de monitorización de pacientes (PMD, por sus siglas en inglés) de una serie de dispositivos médicos y registros manuales. Los registros consisten en la toma de medicación, dieta y actividad física y tareas de aprendizaje y control de la medida del metabolismo. El compromiso general del paciente se comprueba al estimar el uso del sistema y la adherencia del tratamiento y el estado de los objetivos del paciente a corto y largo plazo. El módulo de análisis conductual, que consiste en una serie de reglas y ecuaciones, calcula la conducta del paciente. Tras lograr el análisis conductual, el módulo de gestión de AFM actualiza la lista de AFM y la configuración de los envíos. Las actualizaciones incluyen el número, el tipo y la frecuencia de mensajes. Los AFM los revisa periódicamente el médico que también participa en el perfeccionamiento del tratamiento, adaptado a la fase transteórica actual. Los AFM se segmentan en distintas categorías y niveles y los pacientes pueden ajustar la entrega del mensaje de acuerdo con sus necesidades personales. El EBF se ha puesto en marcha integrado dentro del sistema METABO, diseñado para facilitar al paciente diabético que controle sus condiciones relevantes de una manera menos intrusiva. El dispositivo del paciente se vincula en una plataforma móvil, mientras que una interfaz de panel médico permite que los profesionales controlen la evolución del tratamiento. Herramientas específicas posibilitan que los profesionales comprueben la adherencia del paciente y actualicen la gestión de envíos de AFM. El EBF fue probado en un proyecto piloto controlado de manera aleatoria. El principal objetivo era examinar la viabilidad y aceptación del sistema. Los objetivos secundarios eran también la evaluación de la eficacia del sistema en lo referente a la mejora de la adherencia, el control glucémico y la calidad de vida. Se reclutaron participantes de cuatro centros clínicos distintos en Europa. La evaluación del punto de referencia incluía datos demográficos, estado de la diabetes, información del perfil, conocimiento de la diabetes en general, uso de las plataformas TIC, opinión y experiencia con dispositivos electrónicos y adopción de buenas prácticas con la diabetes. La aceptación y eficacia de los criterios de evaluación se aplicaron para valorar el funcionamiento del marco tecnológico. El principal objetivo era la valoración de la eficacia del sistema en lo referente a la mejora de la adherencia. En las pruebas participaron 54 pacientes. 26 fueron asignados al grupo de intervención y equipados con tecnología móvil donde estaba instalado el EBF: 14 pacientes tenían T1DM y 12 tenían T2DM. El grupo de control estaba compuesto por 25 pa cientes que fueron tratados con atención estándar, sin el empleo del EBF. La intervención profesional tanto de los grupos de control como de intervención corrió a cargo de 24 cuidadores, entre los que incluían diabetólogos, nutricionistas y enfermeras. Para evaluar la aceptabilidad del sistema y analizar la satisfacción de los usuarios, a través de LimeSurvey, se creó una encuesta multilingüe tanto para los pacientes como para los profesionales. Los resultados también se recopilaron de los archivos de registro generados en los PMD, el panel médico profesional y las entradas de la base de datos. Los mensajes enviados hacia y desde el EBF y los archivos de registro del sistema y los servicios de comunicación se grabaron durante las cinco semanas del estudio. Se entregaron un total de 2795 mensajes, lo que supuso una media de 107,50 mensajes por paciente. Como se muestra, los mensajes disminuyen con el tiempo, indicando una mejora global de la adherencia al plan de tratamiento. Como se esperaba, los pacientes con T1DM recibieron más consejos a corto plazo, en relación a su estado. Del mismo modo, al ser el centro de T2DM en cambios de estilo de vida sostenible a largo plazo, los pacientes con T2DM recibieron más consejos de recomendación, en cuanto a dietas y actividad física. También se ha llevado a cabo una comparación de la adherencia e índices de uso para pacientes con T1DM y T2DM, entre la primera y la segunda mitad de la prueba. Se han observado resultados favorables para el uso. En lo relativo a la adherencia, los resultados denotaron una mejora general en cada dimensión del plan de tratamiento, como la nutrición y las mediciones de inserción de glucosa en la sangre. Se han llevado a cabo más estudios acerca del cambio a nivel educativo antes y después de la prueba, medidos tanto para grupos de control como de intervención. Los resultados indicaron que el grupo de intervención había mejorado su nivel de conocimientos mientras que el grupo de control mostró una leve disminución. El análisis de correlación entre el nivel de adherencia y las AFM ha mostrado una mejora en la adherencia de uso para los pacientes que recibieron los mensajes de tipo alertas, y unos resultados no significativos aunque positivos relacionados con la adherencia tanto al tratamiento que al uso correlacionado con los recordatorios. Por otra parte, los AFM parecían ayudar a los pacientes que no tomaban suficientemente en serio su tratamiento en el principio y que sí estaban dispuestos a responder a los mensajes recibidos. Aun así, los pacientes que recibieron demasiadas advertencias, comenzaron a considerar el envío de mensajes un poco estresante. El trabajo de investigación llevado a cabo al desarrollar este proyecto ofrece respuestas a las cuatro hipótesis de investigación que fueron la motivación para el trabajo. • Hipótesis 1 : es posible definir una serie de criterios para medir la adherencia en pacientes diabéticos. • Hipótesis 2: es posible diseñar un marco tecnológico basado en los criterios y teorías de cambio de conducta mencionados con anterioridad para hacer que los pacientes diabéticos se comprometan a controlar su enfermedad y adherirse a planes de atención. • Hipótesis 3: es posible poner en marcha el marco tecnológico en el sector de la salud móvil. • Hipótesis 4: es posible utilizar el marco tecnológico como solución de salud móvil en un contexto real y tener efectos positivos en lo referente a indicadores de control de diabetes. La verificación de cada hipótesis permite ofrecer respuesta a la hipótesis principal: La hipótesis principal es: es posible mejorar la adherencia diabética a través de un marco tecnológico mHealth basado en teorías de cambio de conducta. El trabajo llevado a cabo para responder estas preguntas se explica en este trabajo de investigación. El marco fue desarrollado y puesto en práctica en el Proyecto METABO. METABO es un Proyecto I+D, cofinanciado por la Comisión Europea (METABO 2008) que integra infraestructura móvil para ayudar al control, gestión y tratamiento de los pacientes con diabetes mellitus de tipo 1 (T1DM) y los que padecen diabetes mellitus de tipo 2 (T2DM). ABSTRACT Worldwide there is an exponential growth in the incidence of Chronic Diseases (CDs), such as: hypertension, cardiovascular and respiratory diseases, as well as diabetes mellitus, leading to rising numbers of deaths worldwide (Beaglehole et al. 2008). In particular, the prevalence of diabetes mellitus (DM) is largely increasing among all ages and constitutes a major worldwide health problem. Diabetes was directly responsible for 1,5 million deaths in 2012 and 89 million Disability-adjusted life year (DALYs) (WHO 2014). One of the key dilemmas often associated to CD management is the patients’ adherence to treatments, representing a multi-factorial aspect that requires support in terms of: education, self-management, interaction between patients and caregivers, and patients’ engagement. Measuring adherence is complex and, even if widely discussed, there are still no “gold” standards ((Giardini et al. 2015), (Costa et al. 2015). Patient’s engagement, through participation, collaboration, negotiation, and sometimes compromise, enhance opportunities for optimal therapy in which patients take responsibility for their part of the adherence equation. Engaging and involving diabetic patients in treatment decisions, along with professional expertise, can help foster a patient-centered approach to diabetes care (Martin et al. 2005). Patients’ motivation and empowerment are perhaps the two most relevant intervening factors that directly affect self-management of diabetes care. It has been demonstrated that these two factors play an essential role in prescription adherence, as well as for the successful encouragement of a healthy life-style and other behavioural changes (Heneghan et al. 2013). A personalised education plan is indispensable in order to provide the patient with the appropriate tools needed for the effective self-management of the disease (El-Gayar et al. 2013). Effective communication is at the core of providing patient-centred care since it influences behaviours and attitudes towards a health problem (Frampton et al. 2008). In this regard, interactivity, frequency, timing, and tailoring of text messages may promote adherence to a medication regimen. As a consequence, tailoring text messages to patients can constitute a way of making suggestions and information more relevant and effective (Nundy et al. 2013). In this context, mobile health technologies (mHealth) are playing significant roles in improving adherence to prescribed medications (Krishna et al. 2009). The tailoring of diabetes-specific text messages remains an area of opportunity to improve medication adherence and provide motivation to adults with diabetes but further research is needed to fully understand their effectiveness. Personalized text advices have proven to produce a positive impact on patients’ empowerment, self-management, and adherence to prescriptions (Gatwood et al. 2014). mHealth can be used for offering self-management support programs to diabetes patients and at the same time surmounting the technical and financial difficulties involved in diabetes treatment (Free et al. 2013). The main objective of this research work is to demonstrate that a technological framework, based on behavioural change theories, applied to mHealth domain, allows improving adherence treatment in diabetic patients. The framework, named Engagement Behavioural Feedback Framework (EBF), is built on top of validated behavioural techniques to frame messages, guide the definition of contents and assess outcomes: elements from the Transtheoretical Model (TTM), the Goal-Setting Theory (GST), Effective Health Communication (EHC) guidelines and Principles of Persuasive Technology (PPT) were incorporated. The TTM helps patients to progress to a next behavioural stage, through specific motivated text messages, and allow clinician’s identifying the current stage and tailor its strategies individually. Moreover, TTM guidelines are adopted to set customised goals at a level appropriate to the patient’s stage of change. The GST was used to build rules to be applied for enhancing educational intervention and weight loss objectives. Finally, the EHC guidelines and the PPT were applied to increase the effectiveness of messages. The EBF aims to support patients on improving their prescription adherence and persuade them towards a general improvement in diabetes self-management, by means of personalised text messages, named Automatic Feedback Messages (AFM). After a first profile screening, consisting in identifying meaningful patient characteristics based on treatment needs, attitudes and health care behaviours, customised AFMs are selected by the system, approved by the professional, and finally transferred into the patient interface. During the treatment, the user collects the data into a Patient Monitoring Device (PMD) from a set of medical devices and from manual inputs. Inputs consist in medication intake, diet and physical activity, metabolic measurement monitoring and learning tasks. Patient general engagement is checked by estimating the usage of the system and the adherence of treatment and patient goals status in the short and the long term period. The Behavioural Analysis Module, consisting in a set of rules and equations, calculates the patient’s behaviour. After behavioural analysis is accomplished, the AFM library and the dispatch setting are updated by the AFM Manager module. Updates include the number, the type and the frequency of messages. The AFMs are periodically supervised by the professional who also participates to the refinement of the treatment, adapted to the current transtheoretical stage. The AFMs are segmented in different categories and levels and patients can adjust message delivery in accordance with their personal needs. The EBF was integrated to the METABO system, designed to facilitate diabetic patients in managing their disease in a less intrusive approach. Patient device corresponds in a mobile platform, while a medical panel interface allows professionals to monitoring the treatment evolution. Specific tools allow professional to check patient adherence and to update the AFMs dispatch management. The EBF was tested in a randomised controlled pilot. The main objective was to examine the feasibility and acceptance of the system. Secondary objectives were also the assessment of the effectiveness of system in terms of adherence improvement, glycaemic control, and quality of life. Participants were recruited from four different clinical centres in Europe. The baseline assessment included demographics, diabetes status, profile information, knowledge about diabetes in general, usage of ICT platforms, opinion and experience about electronic devices and adoption of good practices with diabetes. Acceptance and the effectiveness evaluation criteria were applied to evaluate the performance of the technological framework. The main objective was the assessment of the effectiveness of system in terms of adherence improvement. Fifty-four patients participated on the trials. Twenty-six patients were assigned in the intervention group and equipped with mobile where the EBF was installed: 14 patients were T1DM and 12 were T2DM. The control group was composed of 25 patients that were treated through a standard care, without the usage of the EBF. Professional’s intervention for both intervention and control groups was carried out by 24 care providers, including endocrinologists, nutritionists, and nurses. In order to evaluate the system acceptability and analyse the users’ satisfaction, an online multi-language survey, using LimeSurvey, was produced for both patients and professionals. Results were also collected from the log-files generated in the PMDs, the professional medical panel and the entries of the data base. The messages sent to and from the EBF and the log-files of the system and communication services were recorded over 5 weeks of the study. A total of 2795 messages were submitted, representing an average of 107,50 messages per patient. As demonstrated, messages decrease over time indicating an overall improvement of the care plan’s adherence. As expected, T1DM patients were more loaded with short-term advices, in accordance with their condition. Similarly, being the focus of T2DM on long-term sustainable lifestyle changes, T2DM received more reminders advices, as for diet and physical activity. Favourable outcomes were observed for treatment and usage adherences of the intervention group: for both the adherence indices, results denoted a general improvement on each care plan’s dimension, such as on nutrition and blood glucose input measurements. Further studies were conducted on the change on educational level before and after the trial, measured for both control and intervention groups. The outcomes indicated the intervention group has improved its level of knowledge, while the control group denoted a low decrease. The correlation analysis between the level of adherences and the AFMs showed an improvement in usage adherence for patients who received warnings message, while non-significantly yet even positive indicators related to both treatment and usage adherence correlated with the Reminders. Moreover, the AFMs seemed to help those patients who did not take their treatment seriously enough in the beginning and who were willing to respond to the messages they received. Even though, patients who received too many Warnings, started to consider the message dispatch to be a bit stressful. The research work carried out in developing this research work provides responses to the four research hypothesis that were the motivation for the work: •Hypothesis 1: It is possible to define a set of criteria to measure adherence in diabetic patients. •Hypothesis 2: It is possible to design a technological framework, based on the aforementioned criteria and behavioural change theories, to engage diabetic patients in managing their disease and adhere to care plans. •Hypothesis 3: It is possible to implement the technological framework in the mobile health domain. •Hypothesis 4: It is possible to use the technological framework as a mobile health solution in a real context and have positive effects in terms of diabetes management indicators. The verification of each hypothesis allowed us to provide a response to the main hypothesis: The Main Hypothesis is: It is possible to improve diabetic adherence through a mHealth technological framework based on behavioural change theories. The work carried out to answer these questions is explained in this research work. The framework was developed and applied in the METABO project. METABO is an R&D project, co-funded by the European Commission (METABO 2008) that integrates mobile infrastructure for supporting the monitoring, management, and treatment of type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) patients.