Identifying User Requirements for an Integrated E-Health Unit for Diabetes Mellitus

Round 1

Reviewer 1 Report

The manuscript can be accepted as it is. Nevertheless, I include some suggestions for corrections for the improvement of the manuscript:

• I would expect the authors commented on the previous studies focused on the eHealth initiatives for diabetes.
• Strong statements need to be backed up with references throughout the manuscript (especially in the 2. eHealth unit requirements section).
• The authors should provide the directions in Figure 2. Activity Relationship Diagram of the e-health unit.
• In the concluding paragraph, I would expect some managerial insights and general comments, rather than a repetition of the study results.

Author Response

Dear editor,
Below, you can find our revisions /responses regarding the meaningful and very useful comments and points of the reviewers.
Please, note that we have inserted the revised parts in red font.

The manuscript can be accepted as it is. Nevertheless, I include some suggestions for corrections for the improvement of the manuscript:

• I would expect the authors commented on the previous studies focused on the eHealth initiatives for diabetes.

Done. A number of references have been added both in the Introduction as well as the Conclusion’s part.

• Strong statements need to be backed up with references throughout the manuscript (especially in the 2. eHealth unit requirements section).

Done. A number of references have been added both in the Introduction as well as the Conclusion’s part.

• The authors should provide the directions in Figure 2. Activity Relationship Diagram of the e-health unit.

Done. Figure 2 has been revised accordingly to present the directions of the process.

• In the concluding paragraph, I would expect some managerial insights and general comments, rather than a repetition of the study results.

The Conclusion’s part has been rewritten from scratch presenting lessons learned and future directions.

Kindest regards,
Authors.

Author Response File: Author Response.docx

Reviewer 2 Report

The manuscript is novel and includes significant content in regard to COMETECH and its role in improving diabetes care in remote areas. However, the overall clarity of the manuscript was affected by improper use of the English language in many instances and the lack of proper organization of the flow of the information. Significant improvements will be recommended below. I recommend the authors comprehensively re-evaluate the manuscript for English language use before resubmitting it to Diabetology.  

The following are a few of my recommendations:

1- The general flow of the (1. Introduction) section needs refinement and reorganization in a more direct and focused manner.

1. In lines 39-43, what can be inferred from this direct quotation of Krupinski's text? A brief sentence to highlight a needed future direction/a lack in literature has to follow for a better fit.  
2. The statistic (46%) in line 63, please clarify where does this statistic hold true? In Europe or just in Greece and North Macedonia?
3. Please reference the sentence in lines 84-85.

2- Overall revision of the abstract and main text is advised for minor spelling, grammar, and lack of consistency and clarification errors. Some are noted below: 

1. Define the abbreviation (COMETECH) as Continuity of care in MEtabolic diseases through modern TECHnology upon the first mention in the abstract and the main text. The same goes for (IPA) and other abbreviations used throughout the main text.
2. Line 18 in the abstract, kindly clarify “them” by replacing the word with what it refers to.
3. Line 20 in the abstract, are the authors referring to EU citizens? Please clarify that in the abstract.
4. Line 30 in the introduction, “health care systems in the country” Please clarify which country in the text.
5. Line 45 in the introduction, following “equipped”, kindly add “with” to read as “equipped with”.
6. Kindly clarify what “they” refer to in line 46 of the introduction.
7. What do GSM services stand for?
8. Kindly make sure that the entire text is consistently written in either American English or British English according to the journal’s preference. Consistency in using symbols (e.g., Euros vs €). Also, some capitalization and spelling issues are detected in lines 66-69 of the introduction and elsewhere.

3- Please avoid repetition throughout the text. E.g., Lines 136-140 have been mentioned repeatedly in different manners (e.g., in the introduction, discussion and conclusions section).

4- In line 144, please explain how the 1000 citizens are equally balanced, while lines 174-175 mention 600 citizens of Greece vs. 400 Citizens of North Macedonia?

5- Figure 1 is informative and clearly presented, while figure 2 is not clearly elucidated. Is there a significance for the lines between the boxes? Please clarify if they indicate anything specific (e.g., the flow of data/accessibility). I would also recommend indicating (what) is measured at each of the numbered stations and (how) in the figure, even though some insights are provided in the main text that follows. For e.g., is blood draws via a fingertip that pricks the skin lightly to measure blood glucose? How will HbA1c be measured as a point of care? etc.. I would also align the short description that follows to coincide with the number of the stations in the figure. It would be a value to include a visual representation of how different stakeholders of the diabetes management team would be able to remotely access a centralized database of patient information in a confidential and efficient manner, that would ultimately ensure the maximum healthcare benefits of patients from the comprehensive mutidiscplinary team.

6- Please include the reason(s) behind establishing a central e-health unit in Greece as opposed to North Macedonia. 

7- Is there a quality control protocol that ensures proper documentation and storage of the electronic health records?

8- The discussion lacks major points. The section has to be augmented by highlighting the potential weaknesses/strengths of the COMETECH project as compared to other major initiatives that aim to facilitate diabetes care in remote/rural areas. What are the future directions following the implementation of the COMETECH initiative? How is the outcome going to be measured?

Author Response

Dear editor,
Below, you can find our revisions /responses regarding the meaningful and very useful comments and points of the reviewers.
Please, note that we have inserted the revised parts in red font.

The manuscript is novel and includes significant content in regard to COMETECH and its role in improving diabetes care in remote areas. However, the overall clarity of the manuscript was affected by improper use of the English language in many instances and the lack of proper organization of the flow of the information. Significant improvements will be recommended below. I recommend the authors comprehensively re-evaluate the manuscript for English language use before resubmitting it to Diabetology.

Done. A thorough proofreading has been applied and many parts have been revised accordingly. Moreover, the paragraphs that were repeated have been either deleted or rephrased.

The following are a few of my recommendations:

1- The general flow of the (1. Introduction) section needs refinement and reorganization in a more direct and focused manner.

1. In lines 39-43, what can be inferred from this direct quotation of Krupinski's text? A brief sentence to highlight a needed future direction/a lack in literature has to follow for a better fit.
2. The statistic (46%) in line 63, please clarify where does this statistic hold true? In Europe or just in Greece and North Macedonia?
3. Please reference the sentence in lines 84-85.

Done. The text has been revised accordingly for points a, b, and c.

2- Overall revision of the abstract and main text is advised for minor spelling, grammar, and lack of consistency and clarification errors. Some are noted below: 

1. Define the abbreviation (COMETECH) as Continuity of care in MEtabolic diseases through modern TECHnology upon the first mention in the abstract and the main text. The same goes for (IPA) and other abbreviations used throughout the main text.
2. Line 18 in the abstract, kindly clarify “them” by replacing the word with what it refers to.
3. Line 20 in the abstract, are the authors referring to EU citizens? Please clarify that in the abstract.
4. Line 30 in the introduction, “health care systems in the country” Please clarify which country in the text.
5. Line 45 in the introduction, following “equipped”, kindly add “with” to read as “equipped with”.
6. Kindly clarify what “they” refer to in line 46 of the introduction.
7. What do GSM services stand for?
8. Kindly make sure that the entire text is consistently written in either American English or British English according to the journal’s preference. Consistency in using symbols (e.g., Euros vs €). Also, some capitalization and spelling issues are detected in lines 66-69 of the introduction and elsewhere.

Done. The text has been revised accordingly for points a, b, c, d, e, f, g, and h.

3- Please avoid repetition throughout the text. E.g., Lines 136-140 have been mentioned repeatedly in different manners (e.g., in the introduction, discussion and conclusions section).

Done. All the paragraphs that were repeated have been either deleted or rephrased.

4- In line 144, please explain how the 1000 citizens are equally balanced, while lines 174-175 mention 600 citizens of Greece vs. 400 Citizens of North Macedonia?

Done. Lines mention “600 citizens of Greece vs. 400 Citizens of North Macedonia” have been deleted since in the project an (almost) an equal number of patients (~250) have been examined in the four e-health units.

5- Figure 1 is informative and clearly presented, while figure 2 is not clearly elucidated. Is there a significance for the lines between the boxes? Please clarify if they indicate anything specific (e.g., the flow of data/accessibility). I would also recommend indicating (what) is measured at each of the numbered stations and (how) in the figure, even though some insights are provided in the main text that follows. For e.g., is blood draws via a fingertip that pricks the skin lightly to measure blood glucose? How will HbA1c be measured as a point of care? etc. I would also align the short description that follows to coincide with the number of the stations in the figure. It would be a value to include a visual representation of how different stakeholders of the diabetes management team would be able to remotely access a centralized database of patient information in a confidential and efficient manner, that would ultimately ensure the maximum healthcare benefits of patients from the comprehensive mutidiscplinary team.

Done. Figure 2 has been revised accordingly to present the directions of the process.

6- Please include the reason(s) behind establishing a central e-health unit in Greece as opposed to North Macedonia. 

This is because the Lead Beneficiary of the COMETECH project is the International Hellenic University of Greece is located in Thessaloniki.

7- Is there a quality control protocol that ensures proper documentation and storage of the electronic health records?

Done. The following clarification has been added, “The records of the citizens using the COMETECH services can safely and easily accessible by their physicians adopting the Quality of Electronic Health Record System (EHRS)”.

8- The discussion lacks major points. The section has to be augmented by highlighting the potential weaknesses/strengths of the COMETECH project as compared to other major initiatives that aim to facilitate diabetes care in remote/rural areas. What are the future directions following the implementation of the COMETECH initiative? How is the outcome going to be measured?

The Conclusion’s part has been rewritten from scratch presenting managerial implications, lessons learned, and future directions.

Kindest regards,
Authors.

Author Response File: Author Response.docx

Reviewer 3 Report

In this manuscript, the authors describe a collaborative project that aims to address the problem of inadequate access to health services for people living in isolated communities in Greece-North Macedonia cross-border areas.  The project established four e-health units, two in each country, equipped with state-of-the-art medical devices, supported by advanced software applications and medical staff.  These e-health units allow for the recording of patient data, educating people about environmental and other risk factors, and providing medical care services.  This manuscript focuses on the user requirements for establishing e-health units and medical devices, with a focus on telehealth continuity of care for patients with diabetes.   

This is a timely manuscript that describes an important aspect of the development of telehealth via e-health units in isolated cross-border areas. Minor suggestions for strengthening the manuscript are provided below.

1. The abstract does not mention diabetes. Consider adding something to indicate that the focus is on developing telehealth capacity for individuals at risk for diabetes or who have diabetes.
2. It would help if the manuscript were carefully edited by someone whose native language is English. There are numerous problems with the wording, as well as a great deal of repetition.  Although one can understand what is being communicated in general, it would help if the authors could work on developing a more concise and grammatically correct manuscript.  For examples, some minor editing is needed on lines 83, 89, 95, 112, 136,137, 194, 241, 348, and 357-8.  The text in lines 141-144 is garbled and makes no sense.  The text in lines 155-156 is awkward.  In line 237, I think the term “invasively” should be replaced with “non-invasively.”
3. It would help if the authors explained what the acronym COMETECH stands for, if anything.
4. If possible, a simple map showing the locations of the participating institutions would help give the reader a better feeling for these isolated communities.
5. The table labeled Table 34 on line 326 probably should be labeled Table 3. The authors need to reformat the table since the first letter on the far left is truncated for items 1-9.  The authors need to clarify what they are trying to communicate in this table or consider a more visually effective way to communicate the information.  Also, consider integrating the information in Table 2 into a footnote at the bottom of Table 3, depending on whether and how the authors rework Table 3 to clarify what they want the reader to understand from it.

Author Response

Dear editor,
Below, you can find our revisions /responses regarding the meaningful and very useful comments and points of the reviewers.
Please, note that we have inserted the revised parts in red font.

In this manuscript, the authors describe a collaborative project that aims to address the problem of inadequate access to health services for people living in isolated communities in Greece-North Macedonia cross-border areas. The project established four e-health units, two in each country, equipped with state-of-the-art medical devices, supported by advanced software applications and medical staff. These e-health units allow for the recording of patient data, educating people about environmental and other risk factors, and providing medical care services. This manuscript focuses on the user requirements for establishing e-health units and medical devices, with a focus on telehealth continuity of care for patients with diabetes.

This is a timely manuscript that describes an important aspect of the development of telehealth via e-health units in isolated cross-border areas. Minor suggestions for strengthening the manuscript are provided below.

1. The abstract does not mention diabetes. Consider adding something to indicate that the focus is on developing telehealth capacity for individuals at risk for diabetes or who have diabetes.

Done. The focus of the paper/project on diabetes has been provided in the Abstract.

2. It would help if the manuscript were carefully edited by someone whose native language is English. There are numerous problems with the wording, as well as a great deal of repetition. Although one can understand what is being communicated in general, it would help if the authors could work on developing a more concise and grammatically correct manuscript. For examples, some minor editing is needed on lines 83, 89, 95, 112, 136,137, 194, 241, 348, and 357-8. The text in lines 141-144 is garbled and makes no sense. The text in lines 155-156 is awkward. In line 237, I think the term “invasively” should be replaced with “non-invasively.”

Done. Thorough proofreading has been applied and many parts have been revised accordingly. Moreover, the paragraphs that were repeated have been either deleted or rephrased. The Conclusion’s part has been rewritten from scratch.

3. It would help if the authors explained what the acronym COMETECH stands for, if anything.

Done. The acronym has been provided both in the Abstract, as well as in the Introduction.

4. If possible, a simple map showing the locations of the participating institutions would help give the reader a better feeling for these isolated communities.

Done. A map (Figure 1) has been added identifying the targeted geographic areas.

5. The table labeled Table 34 on line 326 probably should be labeled Table 3. The authors need to reformat the table since the first letter on the far left is truncated for items 1-9. The authors need to clarify what they are trying to communicate in this table or consider a more visually effective way to communicate the information. Also, consider integrating the information in Table 2 into a footnote at the bottom of Table 3, depending on whether and how the authors rework Table 3 to clarify what they want the reader to understand from it.

Done. Tables 2 and 3 have been merged to one and a sentence has been added to illustrate the aim of the table.

Kindest regards,
Authors.

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report

I regret to inform the authors that I would need to reject this manuscript based on the major points that follow, which are intended to constructively criticize the work:

1- There is a lot of repetition throughout the manuscript. A more concise approach would make the manuscript easier to read and understand. This impacted the overall flow and clarity of information. Examples: combining the lines 37-49 into one paragraph would deliver a better transition with a meaningful conclusion as opposed to having three separate disconnected paragraphs. There is no need for the paragraph within lines 107-110. Many information presented in the introduction is repeated throughout the manuscript especially in section 2.

2- There are still moderate English language errors that interfere with understanding some sentences (the use of prepositions, the lack of "the" before many nouns, commas). Two examples of sentences that need improvement to transcend their meaning are lines 79-80 & lines 131-133. 

3- Figure 3 needs major clarification that goes hand in hand with the short description that follows. Example: 1- Desktop has to correspond to point (1) in the text that follows. 2- etc.

I would recommend the authors comprehensively re-arrange the content before submitting again. The discussion section has improved significantly, I was wondering since the authors mention that the COMETECH project is almost completed, what is the anticipated data to fully complete this project?

Thank you for giving me the chance to review your work and best of luck.