Patent Publication Number: US-2022230726-A1

Title: Pump with therapy coaching

Description:
RELATED APPLICATIONS 
     This application is a continuation of U.S. application Ser. No. 16/394,751 filed Apr. 25, 2019, which in turn is a continuation of U.S. application Ser. No. 14/797,652 filed Jul. 13, 2015, now abandoned, which in turn is a continuation of U.S. application Ser. No. 14/455,508 filed Aug. 8, 2014, now U.S. Pat. No. 10,052,049 issued Aug. 21, 2018, which in turn is a continuation of U.S. application Ser. No. 12/908,218 filed Oct. 20, 2010, now U.S. Pat. No. 8,801,657 issued Aug. 12, 2014, which in turn is a division of U.S. application Ser. No. 11/970,232 filed Jan. 7, 2008, now abandoned, each of which is hereby fully incorporated herein by reference. 
    
    
     BACKGROUND OF THE INVENTION 
     People who suffer from diabetes require insulin to keep their blood glucose level as close as possible to normal levels. It is essential for people with diabetes to manage their blood glucose level to within a normal range. Complications from diabetes can include heart disease (cardiovascular disease), blindness (retinopathy), nerve damage (neuropathy), and kidney damage (nephropathy). Insulin is a hormone that reduces the level of blood glucose in the body. Normally, insulin is produced by beta cells in the pancreas. In non-diabetic people, the beta cells release insulin to satisfy two types of insulin needs. The first type is a low-level of background insulin that is released throughout the day. The second type is a quick release of a higher-level of insulin in response to eating. Insulin therapy replaces or supplements insulin produced by the pancreas. 
     Conventional insulin therapy typically involves one or two injections a day. The low number of injections has the disadvantage of allowing larger variations in a person&#39;s insulin levels. Some people with diabetes manage their blood glucose level with multiple daily injections (MDI). MDI may involve more than three injections a day and four or more blood glucose tests a day. MDI offers better control than conventional therapy. However, insulin injections are inconvenient and require a diabetic person to track the insulin doses, the amount of carbohydrates eaten, and their blood glucose levels among other information critical to control. 
     It is important for a diabetic person to be treated with the proper amount of insulin. As discussed previously, high blood sugar can lead to serious complications. Conversely, a person with low blood sugar can develop hypoglycemia. Ideally, insulin therapy mimics the way the body works. An insulin pump is one way to mimic the body&#39;s insulin production. An insulin pump can provide a background or basal infusion of insulin throughout the day and provide a quick release or bolus of insulin when carbohydrates are eaten. If a person develops high blood sugar, a correction bolus of insulin can be delivered by the pump to correct it. While insulin pumps improve convenience and flexibility for a diabetic person, they can be sophisticated devices. Some insulin pumps can be difficult to program. Proper use of an insulin pump requires a user to go through a learning curve to properly treat their diabetes using the insulin pump. 
     SUMMARY 
     In an embodiment, an apparatus comprises a pump configured to deliver a drug from a cartridge; a user interface; a memory to store guideline parameters related to use of the apparatus; and a controller communicatively coupled to the pump, the memory, and the user interface, wherein the controller includes: a comparison module configured to compare patient use parameters to the stored guideline parameters; and a scoring module configured to calculate a score indicative of efficacy of patient pump use based on a comparison by the comparison module, and wherein the controller is configured to communicate advice to the user on how to increase the efficacy of patient pump use. 
     In an embodiment, a method comprises monitoring patient use of a device that includes a pump, wherein the monitoring includes comparing patient use parameters to stored guideline parameters; calculating a score indicative of efficacy of patient pump use based on the monitoring; and communicating advice to the user on how to increase pump efficacy. 
     In an embodiment, an apparatus comprises a pump configured to deliver a drug therapy; 
     a memory configured to store a delivery pattern of the drug therapy; a user interface configured to receive time change information; and a controller communicatively coupled to the pump, the memory, and the user interface, wherein the controller includes a timing module configured to shift the delivery pattern in time according to the received time change information. 
     In an embodiment, a method comprises receiving time change information into a device having a pump; and shifting a delivery pattern of the device in time according to the information received into the device. 
     This overview is intended present some subject matter of the patent application. It is not intended to provide an exclusive or exhaustive explanation of the invention. The detailed description is included to provide further information about the subject matter of the present patent application. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIGS. 1A and 1B  illustrate portions of a device that includes an insulin pump. 
         FIG. 2  is a block diagram of portions of an embodiment of a device to adjust delivery of meal-related insulin. 
         FIG. 3  is a flow diagram of an embodiment of a method to provide adjustment to a meal bolus for a pump user. 
         FIG. 4  shows another embodiment of a device to adjust meal-related insulin delivered with an insulin pump. 
         FIG. 5  illustrates a graph of an example of a combination meal bolus of insulin. 
         FIG. 6  illustrates a graph of another example of a combination meal bolus of insulin. 
         FIG. 7  illustrates a graph of an example of this basal insulin shifting. 
         FIG. 8  illustrates a graph of an example of basal insulin delivered at a ramped rate. 
         FIG. 9  is a block diagram of portions of an embodiment of a blood glucose (BG) management device to reduce alarm fatigue. 
         FIG. 10  is a block diagram of portions of another embodiment of a BG management device to reduce alarm fatigue. 
         FIG. 11  is a flow diagram of a method of reducing alarm fatigue in a BG management device. 
         FIG. 12  is a block diagram of portions of an embodiment of a device that helps a patient improve their use of an insulin pump. 
         FIG. 13  is a flow diagram of a method of using a medical device to help a patient improve their use of an insulin pump. 
         FIG. 14  is a block diagram of portions of an embodiment of a device that shifts insulin delivery parameters according to a change in the schedule of a user. 
         FIG. 15  is a flow diagram of an embodiment of a method to shift insulin delivery parameters according to a change in the schedule of a user of an insulin pump. 
         FIG. 16  is a block diagram of portions of an embodiment of a device to determine blood glucose testing times for an insulin pump user. 
         FIG. 17  is a graphical representation of an example of a schedule of blood glucose testing times. 
         FIG. 18  is a block diagram of portions of another embodiment of a device to determine blood glucose testing times for an insulin pump user. 
         FIG. 19  is a flow diagram of portions of method to determine blood glucose testing times for an insulin pump user. 
     
    
    
     DETAILED DESCRIPTION OF THE DRAWINGS 
     Insulin Pumps can be sophisticated devices. Insulin pumps that help coach a person in the use of the device may cause the device to be more effective in treating a person&#39;s diabetes. 
       FIGS. 1A and 1B  illustrate portions of a device  100  that includes an insulin pump. The device  100  includes a cassette or cartridge of insulin. The cartridge is connectable to infusion tubing  140  connectable to a patient such as by a Luer lock  145  or infusion set  142 . The device  100  includes a display  102  and a user interface that may include the display  102  and include one or more keys  104 . Because proper use of an insulin pump requires a user to go through a learning curve to properly treat their diabetes using the pump, it is desirable for a pump to provide assistance to the user, whether the user is a diabetic patient, a caregiver, or a clinician. 
     Adjusting Insulin According to Meals 
     It is important for a diabetic to properly control their blood glucose level. A meal bolus is an amount of insulin delivered in anticipation of, or in response to, eating a meal. Typically, the meal bolus insulin is to counteract or cover the amount the amount of carbohydrates in the meal. The proper amount of insulin can be influenced by many factors such as the nutrient content of the food in the meal. Nutrient content refers to the amount of carbohydrates, protein, and fat in the meal. Determining an appropriate amount of insulin in the meal bolus can be difficult for a pump user and may involve trial and error in finding the right meal bolus for certain meals. 
       FIG. 2  is a block diagram of portions of an embodiment of a device  200  to automatically adjust meal-related insulin delivered with an insulin pump. The device  200  includes a controller  205 . The controller  205  can be implemented using hardware circuits, firmware, software or any combination of hardware, firmware, and software. Examples, include a microcontroller, a logical state machine, and a processor such as a microprocessor, application specific integrated circuit (ASIC), or other type of processor. The controller  205  is configured to perform or execute a function or functions. Such functions correspond to modules, which are software, hardware, firmware or any combination thereof. Multiple functions may be performed in one or more modules. In some examples, software or firmware is provided on a computer readable medium. The computer readable medium includes instructions therein, which when processed (such as by the controller  205  for example) results in a device performing the functions described herein. Examples of a computer readable medium include a compact disc (CD), memory stick, or remote storage accessible via a communication network such as the internet or a cell phone network. 
     The device  200  also includes a pump  210  or pump mechanism to deliver insulin to a subject such as a patient or user. The pump  210  may be a positive displacement pump. Descriptions of an example of a medication pump to deliver insulin are found in Vilks et al., “Cartridge and Rod for Axially Loading a Medication Pump,” U.S. Pat. No. 7,033,338, filed Feb. 28, 2002, which is incorporated herein by reference in its entirety. The device  200  also includes a user interface  215  and an input  220  that, together with the pump  210 , are communicatively coupled to the controller  205 . The communicative coupling allows the controller  205  to exchange electrical signals with the user interface  215 , input  220 , and pump  210  even though intervening circuitry may be present. The input  220  receives information into the device  200  related to managing diabetes of a user. This information may include physiologic data of the patient and/or any indications for the patient, such as any physical indications and indications of a drug therapy the patient is using. The information also may pertain to the meal the patient has eaten or plans to eat. 
     The controller  205  includes an insulin timing module  225  configured to initiate delivery of insulin in a time relation to when a meal is to be consumed by the user and to adjust delivery of the insulin according to the received information. The controller  205  may include a timer  245 . After a timed duration after delivery of the insulin timed by the timer  245  or the insulin timing module  225 , the controller generates a reminder to the user to eat. The reminder may be a visual alert displayed on a display  230  included in the user interface  215 , or the device  200  may include a transducer or speaker and the generated reminder is an audible alert. In another example, the device may include a mechanical vibration mechanism and the generated reminder is a vibratory alert. 
       FIG. 3  is a flow diagram of an embodiment of a method  300  to automatically provide adjustment to a meal bolus for a pump user. At block  305 , information is received into a device having an insulin pump. The received information relates to managing diabetes of a user of the insulin pump device. At block  310 , delivery of insulin is adjusted according to the received information. The insulin is to be delivered by the device in relation to a time period when a meal is to be consumed by the user. The insulin may be delivered as a meal bolus prior to the meal, during the time the meal is scheduled, or after the meal. The insulin may be delivered as a change in a basal insulin rate pattern or profile. 
     Returning to  FIG. 2 , in some embodiments, the information related to managing diabetes of a user includes a blood glucose level of the user. In some embodiments, the device  200  includes a communication port  235  communicatively coupled to the input  220 . The controller  205  is configured to receive information about the blood glucose level of the user via the communication port  235  from a separate second device. In some embodiments, the second device is a blood glucose monitor. In some embodiments, the communication port is a wireless port, such as an infrared (IR) port or a radio frequency (RF) port for example. In some embodiments, the communication port is a wired port, such as a serial port for example. In some embodiments, the controller  205  receives blood glucose information via the user interface  215 , such as when the information is entered using a keypad included in the user interface. 
       FIG. 4  shows another embodiment of a device  400  to automatically adjust meal-related insulin delivered with an insulin pump. The device  400  includes a pump to deliver insulin  410 , a user interface  415 , and an input  420 , communicatively coupled to a controller  405  that includes an insulin timing module  425 . The device  400  also includes a blood glucose monitor  437  communicatively coupled to the input  420 . The blood glucose monitor  437  may be a continuous blood glucose monitor that includes a blood glucose sensor circuit to produce an electrical blood glucose signal representative of a blood glucose level of the patient. The blood glucose sensor circuit may sense blood glucose concentration from blood or from interstitial fluid. The blood glucose sensor circuit may include a sensor interface circuit to sample the blood glucose signal and may provide additional signal processing, such as filtering or amplification for example. The sensor interface circuit may provide sampled blood glucose data to the input  420 . A description of a blood glucose sensor circuit can be found in Steil et al., “Closed Loop System for Controlling Insulin Infusion,” U.S. Pat. No. 6,558,351, filed Jun. 1, 2000, which is incorporated herein by reference in its entirety. 
     It is desirable for diabetics to manage their blood glucose level to within a normal range. Returning to  FIG. 2 , the user may have a meal time scheduled or programmed into the device  200 , and the controller  205  may initiate delivery of insulin in relation to a scheduled meal time. If the blood glucose information indicates that the blood glucose level of the user is low (e.g., the blood glucose level is lower than a threshold blood glucose level), the insulin timing module  225  may delay delivery of a meal bolus of insulin. In some embodiments, the user interface  215  includes a display  230 . If the blood glucose information indicates that the blood glucose level of the user is high (e.g., the blood glucose level is higher than a threshold blood glucose level), the insulin timing module may display a recommendation that the user not eat. In some embodiments, if the blood glucose information indicates that the blood glucose level of the user is high, the insulin timing module may display a recommendation that the user initiate a correction bolus of insulin. 
     According to some embodiments, the information related to managing diabetes received by the controller  205  includes an indication whether the user has abnormal gastric emptying. An example of abnormal gastric emptying is gastroparesis. Gastroparesis refers to a digestive disorder in which the user has delayed emptying of food from the stomach into the lower intestine. The indication of abnormal gastric emptying may be stored in a memory communicatively coupled to the controller  205 . The insulin timing module  225  may delay delivery of meal bolus when abnormal gastric emptying is indicated for the user. 
       FIG. 5  illustrates a graph  500  of an example of a combination meal bolus of insulin. The graph  500  shows an amount of insulin delivered versus time. The combination meal bolus includes a first portion  505  of insulin that is delivered immediately beginning at time to. The first portion  505  concludes at time t 1  when a second portion  510  of insulin begins to be delivered. The second portion  510  is delivered over an extended period of time until time t 2 . The extended portion is delivered at a lower rate and for a longer period of time than the first portion  505 . The combination bolus may be timed by the insulin timing module  225  of  FIG. 2 . If abnormal gastric emptying is indicated for a user, the insulin timing module  225  may change the combination meal bolus. 
       FIG. 6  illustrates a graph  600  of another example of a combination meal bolus of insulin. The combination meal bolus includes a first portion  605  of insulin and a second portion  610  of insulin. The first portion  605  is delivered immediately beginning at time to and concludes at time t 1 . If abnormal gastric emptying is indicated for the user, the insulin timing module  225  generates a delay between the first portion  605  and the second portion  610 . The second portion is delivered beginning after the delay at time t 2  and concludes at time t 3 . 
     According to some embodiments, the information related to managing diabetes of the user of the device  200  of  FIG. 2  includes an indication of a drug the user is taking. The insulin timing module  225 , in response to the indication, recommends at least one of a change in an amount of insulin delivered in a bolus, a change to a user&#39;s total daily dose of insulin, or a change in a frequency of blood glucose checks of the user. 
     For example, the information related to managing diabetes includes an indication that the user is taking a hormone to assist uptake of insulin (e.g., Symlin®). When such a hormone is indicated, the insulin timing module  225  may reduce the amount of insulin delivered in the meal bolus and may recommend a reduction in the user&#39;s total daily dose of insulin. In some embodiments, the insulin timing module  225  may deliver the meal bolus over an extended period of time (e.g., reduce the rate of the meal bolus but provide the bolus over a longer time, such as the extended second portion  510  in  FIG. 5 ). In some embodiments, the insulin timing module  225  may deliver the meal bolus as a combination bolus that includes a first portion that is delivered immediately and a second portion that is delivered over an extended period. 
     In another example, the information related to managing diabetes includes an indication that the user is taking a beta-adrenergic blocking agent. Beta-adrenergic blocking agents may increase the chance of developing either high or low blood glucose levels and may cause a low blood glucose level to last longer than normal. If a beta-adrenergic blocking agent is indicated, the insulin timing module  225  may change the delivery of a meal bolus to counteract a likelihood of a high or low blood glucose level such as by changing the amount of insulin in the meal bolus or delivering the meal bolus as a combination bolus. Beta-adrenergic blocking agents also may cover up symptoms indicative of low blood sugar. For this reasons, the insulin timing module  225  may recommend an increase in blood glucose checks of the user. 
     In another example, the information related to managing diabetes includes an indication that the user is using a corticosteroid. Corticosteroids taken over several weeks such as by being applied to the skin for a long period of time or injected into a joint may increase the blood glucose level of the user. If a corticosteroid is indicated, the insulin timing module  225  may reduce the amount of insulin in a meal bolus. 
     In another example, the information related to managing diabetes includes an indication that the user has consumed some amount of alcohol. Such consumption can increase the effect of insulin to lower blood glucose. If alcohol consumption is indicated, the insulin timing module  225  may reduce the amount of insulin in a meal bolus. 
     According to some embodiments, the information related to managing diabetes of a user includes information related to the nutrient content of the meal eaten or anticipated to be eaten by the user. The controller  205  includes an insulin calculation module  240 . Nutrient content includes an amount of fat, protein, fiber and/or carbohydrates in a meal. The insulin calculation module  240  calculates an amount of insulin to deliver in a meal bolus of insulin to cover an amount of carbohydrates in the meal using a carbohydrate ratio. 
     A carbohydrate ratio refers to the amount of carbohydrates covered by a unit of insulin. It is sometimes referred to as a carbohydrate factor, or carb factor, and is typically specified as grams of carbohydrates per unit of insulin. An insulin pump may use the carbohydrate ratio to automatically determine a carbohydrate insulin bolus amount required to match a number of carbohydrates ingested by the patient, or at least to keep post-meal blood glucose within a range that is healthy for a patient. For example, the patient may plan to eat 70 grams of carbohydrates. If the carbohydrate ratio is 10 grams of carbohydrates per unit of insulin (10 g/u), the insulin pump would determine that 7 units of insulin are required to cover the carbohydrates. An appropriate carbohydrate ratio may vary from person to person, yet it is important for a pump to use an appropriate carbohydrate ratio. Descriptions of systems, devices, and methods to automatically determine a carbohydrate ratio for an insulin pump user are found in Blomquist, “Carbohydrate Ratio Testing Using Frequent Blood Glucose Input,” U.S. patent application Ser. No. 11/679,712, filed Feb. 27, 2007, which is incorporated herein by reference in its entirety. 
     In some embodiments, the insulin calculation module  240  calculates an amount of insulin to deliver in the meal bolus using an amount of protein indicated in the nutrient content of the meal and using a protein ratio. Similar to a carbohydrate ratio, a protein ratio refers to the amount of protein covered by a unit of insulin. In some embodiments, the insulin calculation module  240  calculates an amount of insulin to deliver in the meal bolus using an amount of fat indicated in the nutrient content of the meal and using a fat ratio. A fat ratio refers to the amount of fat covered by a unit of insulin. The insulin calculation module  240  adds the amount of insulin needed to cover the fat and/or protein to the amount of insulin calculated to cover the carbohydrates in order to determine the total meal bolus amount. In some embodiments, the insulin calculation module  240  calculates the amount of insulin to deliver by using the fiber content of the meal to adjust the bolus amount. Typically, the carbohydrate grams of the meal that are from un-metabolized fiber are subtracted from the total grams of carbohydrates eaten. 
     According to some embodiments, the insulin timing module  225  delivers a portion of a meal bolus at or near the beginning of a meal time period. The meal bolus may be scheduled by being pre-programmed into the device  200  or the user may enter the meal time through the user interface  215 . The information related to managing diabetes of a user includes a nutrient content of the meal actually consumed. This information may be entered by the user at the end of a meal. If the nutrient content information indicates the partial meal bolus did not have enough insulin to cover the meal, the insulin calculation module  240  calculates a second portion of the meal bolus to cover the meal using the nutrient content information. For example, assume that carbohydrate ratio for the user is 20 grams of carbohydrates per unit of insulin (20 g/u). Assume the partial meal bolus contained one unit of insulin, or enough to cover 20 grams of carbohydrates. If the nutrient information indicates that the user consumed 50 grams of carbohydrates in the meal, the insulin calculation module  240  calculates that the second portion of the meal bolus should contain 1.5 units of insulin. 
     If the nutrient content information indicates the partial meal bolus had too much insulin to cover what was actually eaten, the insulin calculation module  240  calculates an amount of carbohydrates, to be consumed in addition to the meal, to cover the extra insulin. For example, again assume that carbohydrate ratio for the user is 20 grams of carbohydrates per unit of insulin (20 g/u) and the partial meal bolus contained one unit of insulin, or enough to cover 20 grams of carbohydrates. If the nutrient information indicates that the user only consumed 10 grams of carbohydrates in the meal, the insulin calculation module  240  calculates that user should consume 10 more grams of carbohydrates to cover the extra insulin in the partial meal bolus. The controller  205  may display a recommendation and/or generate an alert indication to the user to consume the additional carbohydrates. 
     The partial meal bolus feature is useful in a situation where the user orders meal but there is a delay between the time a meal bolus is given and the meal actually arrives. The user takes a partial meal bolus before the meal arrives. The user can then enter the amount of carbohydrates that are consumed or will be consumed, and the device calculates the remaining portion of the meal bolus to deliver. The feature is also useful in the situation where the insulin pump user is a child. A parent initiates a partial meal bolus for the child at meal time. The parent then enters the nutrient content information of the meal actually eaten by the child and the insulin calculation module  240  calculates the second portion of the meal bolus according to the information. 
     According to some embodiments, the nutrient content information includes an indication of an amount of fast absorbing carbohydrates. The information may also include and an amount of slow absorbing carbohydrates in the meal. The insulin calculation module  240  calculates an amount of insulin to deliver immediately in a first portion of a meal bolus using an amount of fast absorbing carbohydrates in the meal, and calculates an amount of insulin to deliver over an extended time period using an amount of slow absorbing carbohydrates in the meal, and/or an amount of fat in the meal, and/or an amount of protein in the meal. The meal bolus is delivered as a combination bolus such as those shown in  FIGS. 5 and 6 . The insulin timing module  225  may time the durations of the first and second bolus portions. 
     Automatic determination of an appropriate amount of insulin in the meal bolus can assist an insulin pump user in achieving better control of their blood glucose levels. As described above, the delivery of insulin in a time relation to a meal may be delivered as a change in a basal rate pattern or profile. According to some embodiments, the information related to managing diabetes of a user received by the input  220  includes a delivery pattern of basal insulin to be stored in a memory associated with the controller  205 . The memory may be integral to the controller  205  or separate from the controller  205 . The insulin timing module  225  shifts at least a portion of basal insulin normally delivered during a time period after the meal time to a time period prior to the meal time and decreases an amount of insulin delivered after the meal time period by the amount delivered prior to the meal. 
       FIG. 7  illustrates a graph  700  of an example of this basal insulin shifting. The graph  700  represents the rate of basal insulin delivered to the insulin pump user versus time. Prior to a meal time, basal insulin is delivered at a first rate  705 . As the scheduled meal time approaches, the insulin timing module  225  increases the basal rate at time t 1  to a second rate  710 . At a time t 2  after the meal, the insulin timing module  225  decreases the basal rate to a third rate  715 . The device  200  delivers insulin at the third rate  715  until time t 3 . After time t 3 , insulin is delivered at the first basal rate  705 . In some embodiments, the amount of increase in insulin delivered during interval t 1 -t 2  is substantially the same as the amount of decrease in insulin delivered during time t 2 -t 3 . 
     In some embodiments, the insulin timing module  225  shifts all of the basal insulin to be delivered during a two to three hour period after a meal time to the hour immediately preceding the meal time. After the meal time, the insulin timing module  225  may suspend delivery of basal insulin until all basal insulin that was shifted to a time prior to the meal would have been delivered by the un-shifted basal delivery pattern. In  FIG. 7 , this would increase the amount of insulin delivered during interval t 1 -t 2  and reduce the amount of insulin delivered during time t 2  t 3  to zero. 
     In some embodiments, the meal times are programmed or scheduled into the device  200  of  FIG. 2 , or the device  200  may deduce when meal times occur from missed meal bolus alerts programmed into the device. A missed meal bolus alert may be issued by the device  200  when no meal bolus was delivered by the device  200  at a specified time. Because the meal bolus is delivered before a meal time, the device can deduce the meal time. In some embodiments, the device  200  provides an alert to the user of the shifted basal rate pattern before delivering insulin according to the new pattern. The alert may in the form of an alarm or a display. The user then activates the shifted delivery pattern of basal insulin according to a user response received via the user interface  215 . 
     In some embodiments, the insulin timing module  225  ramps the rate at which the basal insulin is delivered prior to the meal time period. An example is shown in the graph  800  of  FIG. 8 . Prior to a meal time, basal insulin is delivered at a first rate  805 . As the scheduled meal time approaches, the insulin timing module  225  ramps the basal rate beginning at time t 1  up to a second rate  810  at time t 2 . After the meal, the insulin timing module  225  decreases the basal rate to a third rate  815 . In some embodiments, the insulin timing module  225  ramps the basal rate down to the third rate  815  until time t 3 . The device  200  delivers insulin at the third rate  815  until time t 4 . After time t 3 , insulin is delivered at the first basal rate  805 . In some embodiments, the amount of increase in insulin delivered during interval t 1 -t 3  is substantially the same as the amount of decrease in insulin delivered during time t 3 -t 4 . 
     Avoiding Alarm Fatigue 
     An insulin pump may provide an alarm or other kind of alert to prompt the user to do certain actions that help ensure the user is making effective use of their pump. These alerts may include a reminder to the user to initiate a blood glucose measurement. Recurrent blood glucose measurements may be necessary to give a patient a good overall view of their blood glucose management. An alert to measure blood glucose may be generated a timed interval after a meal, after a correction bolus has been delivered, or after the user has had a high or low blood glucose reading. Because it is optional for the user to test their blood glucose when these alerts occur, many users get in the habit of routinely canceling the alert and not checking their blood glucose. This is sometimes referred to as alarm fatigue. Thus, it is desirable to make it more difficult or less likely for the user to ignore the alert. 
       FIG. 9  is a block diagram of portions of an embodiment of a blood glucose (BG) management device  900  to reduce alarm fatigue. The device  900  includes a controller  905  communicatively coupled to a user interface  915  and an input  920 . The input  920  receives blood glucose information into the device  900 . The information includes a blood glucose level of the user. The controller  905  includes an alert module  950  to provide an alert to the user via the user interface  915 . The alert notifies the user to check their blood glucose level. 
     The controller  905  also includes a blood glucose stability module  955  to calculate a measure of a past stability of the blood glucose level of the user using at least a portion of past blood glucose levels. In some embodiments, the blood glucose stability module  955  trends the measure. In some embodiments, the blood glucose stability module  955  measures a central tendency of the blood glucose level of the user, such as an average blood glucose value or a median blood glucose value for example. In some embodiments, the blood glucose stability module  955  measures a maximum blood glucose level of the user. In some embodiments, the blood glucose stability module  955  measures a minimum blood glucose level of the user. In some embodiments, the blood glucose stability module  955  measures a standard deviation of the blood glucose level of the user. 
     The controller  905  also includes a randomization module  960 . According to the measure of the past blood glucose stability, the randomization module  960  randomizes the alert function of the device  900 . For example, the randomization module  960  may set the likelihood of the device  900  generating an alarm based on the historical stability of the blood glucose level of the user. Users that have stable blood glucose levels are rewarded with fewer alerts to check their blood glucose level. 
     The randomization module  960  may randomize a type of alert to provide or may randomize whether to provide the alert to the user at all. For example, the device  900  may randomize whether to generate a Check Blood Glucose alarm after eating or after taking a correction bolus. The randomization module  960  may randomize a method needed to deactivate an alert or alarm by randomizing a user input to the user interface  915  needed to reset a provided alert. 
     In some embodiments, the alert module  950  includes a timer  945 , and the alert module  950  provides an alert a timed duration after the blood glucose information indicates that the blood glucose level of the user differs from a target blood glucose level by a threshold value. In some embodiments, the device  900  includes a communication port  935  coupled to the input  920  and the communication port configured to receive the blood glucose information from a second separate device. For example, the second device may be a blood glucose monitor, or a device that communicates blood glucose information received from a blood glucose monitor. In some embodiments, the communication port  935  is a wireless port such as an IR port or an RF port. In some embodiments, the communication port  935  is a wired port, such as a serial port for example. 
       FIG. 10  is a block diagram of portions of another embodiment of a BG management device  1000  to reduce alarm fatigue. The device  1000  includes a controller  1005 , a user interface  1015 , and an input  1020 . The controller  1005  includes an alert module  1050 , a blood glucose stability module  1055 , and a randomization module  1060 . In some embodiments, the user interface  1015  includes a display  1030  and the alert module  1050  provides the alert through the display  1030 . In some embodiments, the user interface  1015  includes a speaker  1034 , and the randomization module  1060  randomizes an audible indication of an alert, or an audible aspect of the alert, via the user interface  1015 . In some embodiments, the randomization module  1060  randomizes whether the alert is visual or audible. In some embodiments, the user interface  1015  includes a plurality of keys  1032  to be pressed by a user of the device  1000 . The randomization module  1060  randomizes a sequence of key presses needed to reset a generated alert. 
     According to some embodiments, the BG management device  1000  is an insulin pump and includes a pump  1010  to deliver insulin. The alert module  1050  includes a timer  1045  and the alert module is configured to provide an alert (e.g., to check the blood glucose level) a timed duration after delivery of a bolus of insulin. 
     According to some embodiments, the BG management device  1000  includes a blood glucose monitor  1037  communicatively coupled to the input  1020  and the input  1020  receives the blood glucose information from the blood glucose monitor. In some embodiments, the user interface  1015  is configured to receive manual entry of the blood glucose information from the user. In some embodiments, the user interface  1015  includes a display  1030 . The controller  1005  prompts the user, via the display  1030 , to begin a blood glucose measurement using a second separate device. 
       FIG. 11  is a flow diagram of a method  1100  of reducing alarm fatigue in a BG management device. At block  1105 , it is determined that an alert to check blood glucose level is to be provided to a user of the BG management device. This may be because the device determines the blood glucose level of the device user differs from a target blood glucose level by more than a specified threshold value. At block  1110 , a measure of a past stability of the blood glucose level of the user is calculated by the BG management device. 
     At block  1115 , the device randomly determines, according to the measure of the past stability, at least one of whether to provide the alert to the user, a type of the alert to provide, or a method of receiving an alert reset into the BG management device. Randomly changing the tone or changing the key input needed to cancel the alarm or alert makes it less likely the user will cancel the alarm out of habit and makes it more likely to use the alert feature. 
     Scoring Insulin Pump Use 
     It would be helpful to an insulin pump user if the insulin pump were able to communicate how well the person was using the device, and to communicate advice on how to improve their use. This may increase efficacy of the pump and thereby increase the benefit to the patient. 
       FIG. 12  is a block diagram of portions of an embodiment of a device  1200  that helps a patient improve their use of an insulin pump included in the device  1200 . The device  1200  includes a controller  1205  communicatively coupled to a pump  1210  to deliver insulin, a user interface  1215 , and a memory  1240 . The memory  1240  is to store guideline parameters related to use of the device  1200 . The guideline parameters are ideal parameters, or range of values for a parameter, that an insulin pump user would meet if the user were making the best use of their insulin pump. The guideline parameters may include default parameters and/or include parameters programmed into the device  1200  by a diabetes professional. The programming may be done using the user interface  1215  or by communicating with the device  1200  using a second separate device via a communication port coupled to the input  1220 . Examples of parameters include parameters related to the user checking their blood glucose, parameters related to insulin cartridge use, parameters related to the dietary habits of the user, and parameters related to using the features of the insulin pump. 
     The controller  1205  includes a comparison module  1225  and a scoring module  1230 . The comparison module  1225  monitors the patient&#39;s use of the device  1200  and compares parameters related to the patient&#39;s use to the guideline parameters stored in memory  1240 . The scoring module  1230  calculates a score based on the monitored patient use and is indicative of the efficacy of the patient&#39;s insulin pump use. The score reflects how well the patient is following best practices for insulin pump users. Based on the score, the controller  1205  communicates advice to the user on how to increase pump efficacy (e.g., how to bring the values of the patient&#39;s use parameters toward the guideline parameter values). A higher score indicates that the patient is following guidelines established by their health care provider (e.g., a diabetes professional) and indicates the patient is following best practice in controlling their blood glucose. 
     In some embodiments, the user interface  1215  includes a display  1245 . The controller  1205  may prompt the user, via the display, to begin a blood glucose measurement using a separate device. The user interface  1215  may include keys for receiving manual entry of the blood glucose information into the device from the user. 
     According to some embodiments, the stored guideline parameters are related to a user entering blood glucose readings into the device  1200 . In some embodiments, the stored guideline parameters include the frequency with which blood glucose readings are entered into the device. The comparison module  1225  records (e.g., stores) and compares the frequency with which blood glucose readings are entered into the device  1200  by a user to the guideline frequency stored in memory. The scoring module  1230  determines a score based on how closely the user&#39;s frequency of entering readings matches the guideline frequency. In some embodiments, the stored guideline parameters include the timing of the blood glucose readings. For example, the guideline parameters may specify one or more times of day that the user is to enter a blood glucose reading. The comparison module  1225  compares the actual times the user enters blood glucose readings to the stored parameter guideline times, and the scoring module  1230  determines a score based on how closely the user&#39;s times match the guideline times. 
     According to some embodiments, the stored guideline parameters are related to the dietary habits of the user. In some embodiments, the stored guideline parameters include an amount of carbohydrates, such as a guideline amount for the user to eat during a scheduled meal for example. The comparison module  1225  compares the amount of carbohydrates, entered into the device  1200  as having been eaten by the user, to the stored guideline amount of carbohydrates. In some embodiments, the stored guideline parameters include a number of between meal snacks. The comparison module  1225  compares the number of between meal snacks, entered into the device  1200  as having been eaten by the user, to a stored guideline number of between meal snacks. The scoring module  1230  scores the dietary habits of the user accordingly. 
     In some embodiments, the stored guideline parameters include a difference value in the timing of patient meal times. The comparison module  1225  compares actual meal times entered into the device  1200  by a user to scheduled meal times and determines any differences in the meal times. The comparison module  1225  then compares to one or more time difference values in the meal times to the stored guideline meal time difference value. The scoring module  1230  assigns a higher score for consistency in meal times higher than for a large variation in meal times. In some embodiments, the stored guideline parameters include the frequency with which a user fails to initiate a meal bolus before eating. The comparison module records whether a user fails to take a meal bolus before eating. The comparison module  1225  compares the frequency that meal boluses are missed to a stored guideline value for an allowed frequency of missed meal boluses. The scoring module  1230  generates a lower score for more missed meal boluses. 
     According to some embodiments, the stored guideline parameters are related to insulin cartridge use and/or infusion set use. In some embodiments, the stored guideline parameters include the frequency with which the user changes insulin cartridges. The device  1200  may include a circuit to detect when the cartridge is changed. The comparison module  1225  compares the frequency of actual cartridge changes by a user to the stored guideline insulin cartridge change frequency value. The scoring module  1230  generates higher score for how closely the user&#39;s frequency of changes matches the stored guideline. Not changing the insulin cartridge often enough risks insulin clotting or losing effectiveness of the insulin due to exposure to higher temperatures. 
     In some embodiments, the stored guideline parameters include the frequency with which the user changes infusion sets. The comparison module  1225  compares the frequency of actual infusion set changes as indicated by a user to the stored guideline infusion set change frequency value. The scoring module  1230  generates higher score for how closely the user&#39;s frequency of actual infusion set changes matches the stored guideline. Not changing the infusion set often enough may result in infections. 
     In some embodiments, the stored guideline is the frequency that insulin cartridges for the device  1200  become empty, thereby interrupting therapy. The comparison module  1225  compares the frequency that the user allows insulin cartridges to empty to the stored guideline frequency value. Allowing insulin cartridges to empty often may indicate that the user is not paying proper attention to their device  1200  and the scoring module  1230  provides a higher score the closer the actual frequency that insulin cartridges become empty matches the guideline frequency. In some embodiments, the stored guideline parameters include the difference in timing between insulin cartridge changes. The comparison module  1225  compares the difference in times between insulin cartridge changes to a stored guideline difference value. The scoring module  1230  would score consistency in insulin cartridge changes higher than a large variation in time between insulin cartridge changes. 
     According to some embodiments, the stored guideline parameters are related to use of the features of the device  1200 . In some embodiments, the stored guideline parameters include the frequency that a user uses the test features of the device  1200 . For example, the device  1200  may include a carbohydrate ratio test feature. Descriptions of devices and methods that perform a carbohydrate ratio test are found in Blomquist, “Carbohydrate Ratio Testing Using Frequent Blood Glucose Input,” U.S. patent application Ser. No. 11/679,712, filed Feb. 27, 2007, which is incorporated herein by reference in its entirety. The device  1200  may include a basal rate test feature. Descriptions of devices and methods that perform a basal rate test are found in Blomquist et al., “Basal Rate Testing Using Frequent Blood Glucose Input,” U.S. patent application Ser. No. 11/685,617, filed Mar. 13, 2007, which is incorporated herein by reference in its entirety. The device  1200  may include a correction factor test feature. Descriptions of devices and methods that perform a correction factor test are found in Blomquist et al., “Correction Factor Testing Using Frequent Blood Glucose Input,” U.S. patent application Ser. No. 11/626,653, filed Jan. 24, 2007, which is incorporated herein by reference in its entirety. The comparison module  1225  compares the frequency with which a user uses a test feature of the device  1200  and compares the frequency to a stored guideline device test frequency value. The scoring module  1230  generates a higher score if the user uses the test features more often. 
     In some embodiments, the device  1200  includes a feature that generates a device report. The controller  1205  is configured to store events in the memory  1240 . Examples of such events include historical insulin delivery information and recorded use parameters. In some embodiments, the controller  1205  displays the report using a display  1245  included in the device  1200 . In some embodiments, device  1200  includes communication port and the controller  1205  communicates information to a second separate device via the communication port for formatting and display or printing of the report. The stored guideline parameters include the frequency with which a user views a generated report. The comparison module  1225  compares the frequency with which a user views a pump generated report to a stored report-view frequency value. 
     In some embodiments, the device includes one or more alert features. These alerts may include a reminder to the user to initiate a blood glucose measurement (e.g., after a meal of after a correction bolus), or after the user has had a high or low blood glucose reading. The user interface  1215  may include a display  1245  to provide a visual alert, a speaker or transducer to provide an audible alert, and/or a mechanism to provide a vibratory alert. 
     In some embodiments, the stored guideline parameters include an alert response time. The comparison module  1225  determines the time from when an alert is generated by the device  1200  to the time when the user responds to the alert. The comparison module  1225  compares the user response time to the stored guideline response time value. The scoring module  1230  generates a higher score if the user&#39;s response times are within the guideline response time. In some embodiments, the stored guideline parameters include the total time that the device  1200  may be inoperative. The comparison module  1225  compares the total time that a user renders the device  1200  inoperative to the guideline time. The scoring module  1230  generates a higher score the more often the user uses the device  1200 . 
     In some embodiments, the device  1200  includes an input  1220 . Blood glucose information is received into the device  1200  via the input  1220 . The blood glucose information may include one or more blood glucose levels of the user. In some embodiments, the device  1200  includes a blood glucose monitor communicatively coupled to the input  1220 . The blood glucose monitor may be communicatively coupled via a wireless port or a wired port. The blood glucose monitor may be a continuous blood glucose monitor. In some embodiments, the device  1200  includes a communication port coupled to the input  1220  and configured to receive blood glucose information from a second separate device. The communication port may be a wireless communication port (e.g., IR or RF) or may be a wired port (e.g., a serial port). 
     The comparison module  1225  monitors the blood glucose level of the patient using the information. In some embodiments, the comparison module  1225  determines and monitors a central tendency of the blood glucose level of the user from the information, such as the average value or median value for example. In some embodiments, the comparison module  1225  uses the blood glucose information to determine and monitor a standard deviation of the user&#39;s blood glucose level. In some embodiments, the comparison module  1225  uses the blood glucose information to determine and monitor an amount of insulin delivered in any correction boluses as a percentage of TDD. As described previously, the input  1220  may be communicatively coupled to the input and the blood glucose information is received by manual entry of the information into the device  1200 . 
     According to some embodiments, the stored guideline parameters are related to the user&#39;s management of their blood glucose level. In some embodiments, the stored guideline parameters may include a number of times that the user is allowed to neglect taking a correction bolus when the blood glucose information indicates that the blood glucose of the patient exceeds a target blood glucose level by a threshold value. Of course, the stored number of times may be zero. The comparison module  1225  compares the number of times that the patient did not initiate a correction bolus to the stored guideline number of times. The scoring module  1230  generates a higher score the closer the actual number is to the stored number. 
     In some embodiments, the stored guideline parameters are related to the user&#39;s rechecking their blood glucose some interval after receiving a correction bolus, or some interval after treating a low blood glucose level. The comparison module  1225  compares the number of times that the patient failed to recheck their blood glucose to the stored guideline number of times. In some embodiments, the stored guideline parameters include a number of times that the user is allowed to neglect to recheck blood glucose after a bolus of insulin is delivered by the device  1200 . The comparison module  1225  compares the number of times that the patient failed to recheck their blood glucose to the stored guideline number of times. The scoring module  1230  generates a higher score the closer the actual number is to the stored number. 
     According to some embodiments, the scoring module  1230  trends the calculated score. The controller  1205  may display the score and/or the score trend on the display  1245  when prompted to do so (e.g., through the user interface  1215 ). Such a trend may be included in a device-generated report. When calculating the score, the scoring module  1230  assign different weights to outcomes of the comparisons described. For example, the scoring module may assign a higher weight to the user making consistent blood glucose measurements higher than the user using test features of the device. 
     The controller  1205  communicates advice to the user on how to increase pump efficacy based on the calculated score. For example, if the controller  1205  determines that there is a poor score for taking meal boluses, the controller  1205  may display to the user that the patient&#39;s overall use of the device may be improved by paying more attention to meal boluses. In some embodiments, the device  1200  includes a communication port and the advice on how to increase pump efficacy is communicated to a second separate device. 
     In some embodiments, the scoring can be implemented into a game. This may be useful to encourage young insulin pump users (e.g., children) to become interested in learning about their pump. The score may be communicated to a second separate device (e.g., a computer). The second device could print certificates when the user meets or exceeds one or more threshold scores. The device  1200  or the second device can offer advice on how to increase the pump user&#39;s score. The certificates could be redeemable (e.g., by the manufacturer). 
       FIG. 13  is a flow diagram of a method  1300  of helping a patient improve their use of the insulin pump using a medical device. At block  1305 , patient use of a device is monitored. The device includes a pump configured to deliver insulin. The patient use may be monitored using the insulin pump device, and the monitoring includes comparing patient use parameters to stored guideline parameters. Examples of the parameters include parameters related to a user entering blood glucose readings into the insulin pump, parameters related to the dietary habits of the user, parameters related to insulin cartridge use, parameters related to use of the features of the insulin pump, and parameters related to the user&#39;s management of their blood glucose level. 
     At block  1310 , the medical device calculates a score based on the monitored patient use. The medical device may weigh some parameters higher than others when calculating the score. At block  1315 , advice is communicated to the user or patient on how to increase pump efficacy. 
     Shifting Insulin Therapy Parameters in Time 
     An insulin pump provides insulin therapy to a user using one or more delivery parameters. An example of such a parameter is a basal rate pattern. Basal rate refers to a type of twenty-four hour background infusion of insulin by an insulin pump that mimics the continuous background release of insulin from a normal pancreas. It is the rate of insulin delivery the patient normally needs independent of the consumption of meals. The basal rate is typically specified in insulin units per hour (u/hr). The variation in the rate as a function of time can be referred to as a basal rate pattern or profile. Sometimes it is desirable to vary the basal rate pattern throughout the day to deliver a different basal rate according to a patient&#39;s needs, such as delivering basal insulin at a different rate when the insulin pump user is sleeping than when the user is awake. Other parameters may also have different optimum values at different times of the day. 
     A change in the user&#39;s schedule may cause the appropriate values of the delivery parameters to change. If the pump user travels and crosses time zones, their circadian clock doesn&#39;t immediately adjust to the new time, because, as with jet lag, it takes time for the user&#39;s body to adjust. Consequently, the delivery parameters may no longer be programmed appropriately. If the user adjusts the clock on their insulin pump to match the new time zone, they will instantly adjust their basal rate pattern to the new time. This may not be appropriate because the user&#39;s body clock will be expecting basal insulin according to the old time zone. For example, if the user travels from the Pacific Time Zone to the Eastern Time Zone and adjusts the clock on their insulin pump three hours later, extra basal insulin scheduled for delivery at 2:00 AM will be delivered at 2:00 AM in the Eastern Time Zone while the user&#39;s body clock acts as though it is still 11:00 PM. 
     A better approach would be to not instantly shift the basal rate pattern to the new time when the insulin pump clock is adjusted. Instead the basal rate pattern should be gradually shifted (e.g., once per day) until the basal rate pattern was synchronized to the local time. A similar adjustment would be made on the return home to the original time zone. On a short trip, the basal rate pattern may not be fully adjusted to the new time. Additionally, the basal rate pattern could be gradually adjusted anytime the clock on the insulin pump was changed, such as during a change to or from daylight savings time. 
       FIG. 14  is a block diagram of portions of an embodiment of a device  1400  that shifts insulin delivery parameters according to a change in the schedule of a user of the device  1400 . The device  1400  includes a controller  1405  communicatively coupled to a pump  1410  configured to deliver insulin, a user interface  1415 , and a memory  1440 . The memory  1440  stores a delivery pattern of basal insulin. Time change information is received into the device  1400  through the user interface  1415 . The user interface  1415  may include one or more keys or buttons for the user to enter the time change information. The controller  1405  includes a timing module  1425  configured to shift the delivery pattern of basal insulin in time according to the received information. 
     In some embodiments, the time change information includes travel information of the user. The travel information may include a destination of the user, or only the change in time zones the travel will involve. The travel information may include a travel departure time and travel return time. The timing module  1425  shifts the delivery pattern of basal insulin in time according to a destination time zone indicated in the travel information, and may restore the delivery pattern to its original time based on the travel return time. For example, in some people there is a “dawn phenomenon” where extra insulin is needed near 1 AM or 2 AM. Such a person may have a basal rate pattern that increases at that time. If the user travels from the Eastern Time Zone to the Pacific Time Zone, the timing module  1425  shifts the delivery pattern of basal insulin three hours later. Thus, if the basal rate pattern includes the increase during the early morning hours, the timing module  1425  would shift the increase later in time by three hours. If the travel information includes a return time, the timing module  1425  would shift the back to the original time three hours earlier upon the return time. 
     In some embodiments, the timing module  1425  shifts the delivery pattern of basal insulin by a specified amount of time per time period (e.g., by a fraction of an hour once per day, or a number of hours once per day) until the delivery pattern matches the destination time zone, and shifts the delivery pattern of basal insulin back by the same or a different amount of time until the delivery pattern matches the return time zone according to the return time. For example, if the user travels from the Eastern Time Zone to the Pacific Time Zone, the timing module  1425  shifts the delivery pattern of basal insulin by one-half hour per day until the delivery pattern is shifted three hours later. When the user returns as indicated by the return time or by an indication provided by the user via the user interface, the timing module  1425  begins shifting the delivery pattern earlier by a specified amount of time (e.g., the half hour once per day in the example) until the delivery pattern return to its original time. 
     In some embodiments, the time change information includes a change in local time, such as a change to or from daylight savings time. The timing module  1425  shifts the delivery pattern by a specified amount of time per time period until the delivery pattern matches the time change. 
     In some embodiments, the memory  1440  includes an indication of a sleep segment of the basal insulin delivery pattern. For example, the delivery pattern may repeat every twenty-four hours and a portion of the twenty-four hour period is designated as a sleep segment. Based on the time change information, the timing module  1425  shifts the sleep segment of the basal insulin delivery pattern. 
     According to some embodiments, the memory  1440  also stores other parameters related to the delivery of insulin. The controller  1405  may be configured (e.g., by programming) to change the value of these parameters according to the time of day. The insulin therapy for the user may improve by shifting these parameters in time according to a change in schedule of the user (e.g., due to travel). In some embodiments, the device  1400  may use a different correction factor at a different time of the day according to a time of day schedule. The timing module  1425  may shift the time of day schedule for the correction factor according to the time change information received into the device  1400  and stored in the memory  1440 . In some embodiments, the device  1400  may use a different carbohydrate ratio at a different time of the day according to a time of day schedule. The timing module  1425  may shift the time of day schedule for the correction factor according to the travel information received into the device  1400 . 
       FIG. 15  is a flow diagram of an embodiment of a method  1500  to shift insulin delivery parameters according to a change in the schedule of a user of an insulin pump. At block  1505 , information is received into a device having an insulin pump. The information may relate to local time change of a user of the insulin pump. At block  1510 , the insulin pump device automatically shifts a delivery pattern of basal insulin in time according to the information received into the device. This insulin pump device may be configured to automatically make the shift by logic circuitry implemented in the device. The logic circuitry may include hardware, firmware, or software or any combination of hardware, firmware, or software. 
     Auto Adjustment of Blood Glucose Testing Time 
     Proper management of blood glucose by insulin pump users includes periodic measurement of the user&#39;s blood glucose. For example, this may involve the user taking a blood glucose measurement to determine whether a correction bolus is needed or whether a meal bolus was effective. Testing blood glucose at proper times may give the patient a more accurate picture of their blood glucose control. This can be done by determining statistically significant, or historically significant, blood glucose sampling times and prompting the patient to measure their blood glucose at these times will give the patient that more accurate picture of their blood glucose control. 
       FIG. 16  is a block diagram of portions of an embodiment of a device  1600  to automatically determine blood glucose testing times for an insulin pump user. The device  1600  includes a controller  1605  communicatively coupled to a user interface  1615  and an input  1620 . The input  1620  receives blood glucose data of the insulin pump user into the device  1600 . The blood glucose data is obtained during a number of specified blood glucose testing times. The controller  1605  includes a blood glucose data module  1625 . 
     The blood glucose data module  1625  calculates a measure of the user&#39;s blood glucose variability from the blood glucose data. In some embodiments, the blood glucose data module calculates a measure of statistical variability of the user&#39;s blood glucose such as one or more of a standard deviation of the blood glucose data, an average deviation of the blood glucose data, a variance of the blood glucose data, or a range of the blood glucose data. The controller  1605  adjusts a blood glucose testing time in response to the measure of blood glucose variability. For example, the measure of blood glucose variability may indicate that the user&#39;s blood glucose level is stable at certain times of the day and varies at other times of the day. The controller  1605  automatically adjusts one or more testing times to cover the period of greater variability. 
     In some embodiments, the device  1600  includes a display  1630 . The controller  1605  prompts the user, via the display  1630 , to initiate a blood glucose test. In some embodiments, the device includes a speaker or transducer communicatively coupled to the controller  1605  and provides an audible prompt to the user. The controller  1605  adjusts the blood glucose testing times by changing the times that it prompts the user to initiate a test. 
     According to some embodiments, the controller  1605  includes a comparison module  1655 . The comparison module  1655  compares the measure of blood glucose variability to a threshold blood glucose variability value. The controller  1605  increases the number of blood glucose testing times if the measure of blood glucose variability exceeds a blood glucose variability target value by more than a first threshold blood glucose variability value. The controller  1605  decreases the number of blood glucose testing times if the measure of blood glucose variability is less than the blood glucose variability target value by more than a second threshold blood glucose variability value. This rewards the user with less testing times if the user is managing to keep their blood glucose relatively stable at a normal level. 
     In some embodiments, the device  1600  includes a memory  1640  communicatively coupled to the controller  1605 . The memory  1640  stores an indication of a user preference for a blood glucose testing time. The controller  1600  adjusts the blood glucose testing time according to the indication. The indication may specify that fewer tests be requested by the device  1600  during certain times of the day. For example, the patient may specify that the device  1600  may request no more than two tests per week between the hours of 11:30 PM and 6:00 AM. The indication may be programmed into the device via the user interface  1615 . The device  1600  limits the request for a blood glucose test as indicated even though the blood glucose data may show significant variation during that time. 
     In some embodiments, the controller  1605  creates or updates a schedule of a plurality of blood glucose testing times according to the patient indication and/or the measure of blood glucose variability provided by the blood glucose data module  1625 . The schedule may be stored in memory  1640 . 
       FIG. 17  is a graphical representation of an example of a schedule  1700  or plan of blood glucose testing times. A circle  1705  in the schedule indicates a device  1600  prompt for user to initiate a blood glucose test. The schedule  1700  may be created by the controller  1605  and stored in memory  1640 , or an initial schedule  1700  may be programmed into the memory  1640  (e.g., by a care provider) and the controller  1605  adjusts the blood glucose testing times in the schedule  1700  according to the measure of blood glucose variability and/or indicated patient preferences. The schedule  1700  shown illustrates six test times per day over a period of five days, and the prompts are shown in relation to meal times and sleep times of the patient. Throughout the five days, the six testing times are staggered on different days to obtain blood glucose data at various times. The number of days and number of tests per day may be indicated by patient preference in the memory  1640 . For the example shown, the controller  1605  may have created the schedule  1700  due to a patient indication of no more than five days of testing per week, no more than six tests per day, and no more than three overnight tests per week. The controller  1605  schedules the testing times based on the preferences and on the historical variation in blood glucose of the patient. 
     As additional blood glucose data is collected. The controller  1605  may make further adjustments to the schedule  1700 . Based on the blood glucose variability, the controller  1605  may change the testing times, add testing times (unless disallowed by preferences), or subtract testing times (as indicated  1710  on day 5). The blood glucose testing plan helps the patient to have a more comprehensive picture of their daily blood glucose by changing the times that the blood glucose tests are requested. According to some embodiments, the device  1600  is a blood glucose monitor. The device  1600  prompts the user to initiate a blood glucose test, such as via the display  1630  for example. 
       FIG. 18  is a block diagram of portions of another embodiment of a device  1800  to automatically determine blood glucose testing times for an insulin pump user. The device  1800  includes a controller  1805 , a user interface  1815 , and an input  1820 . The device  1800  also includes a pump  1810  to deliver insulin communicatively coupled to the controller  1805 . The input  1820  receives blood glucose data of the insulin pump user into the device  1800 . The controller  1805  includes a blood glucose data module  1825  to calculate a measure of the user&#39;s blood glucose variability from the blood glucose data. 
     In some embodiments, the controller  1805  adjusts the blood glucose testing time in response to the measure of blood glucose variability and according to times of insulin delivery. For example, the controller  1805  may schedule a blood glucose testing time to occur a timed duration after the insulin pump user initiates a meal bolus. This may be useful to monitor whether the meal bolus properly controls the user&#39;s blood glucose after meal time. In another example, the controller  1805  may schedule a blood glucose testing time to occur a timed duration after a change to a basal insulin rate pattern. This may be useful to monitor the effect of an increase or decrease in basal rate on the user&#39;s blood glucose. 
     In some embodiments, the user interface  1815  includes a display  1830 . To obtain blood glucose data the controller  1805  prompts the insulin pump user, via the display  1830 , to test blood glucose using a separate device. The controller  1805  adjusts the blood glucose testing times by prompting the user to initiate a blood glucose measurement at a different time. In some embodiments, the user interface  1815  includes one or more keys or buttons, and the user interface  1815  and the input  1820  are configured to receive the blood glucose data by manual entry of the data by the user. 
     In some embodiments, the device  1800  includes a communication port  1835  communicatively coupled to the input  1820  as shown in  FIG. 16 . The communication port  1635  may be a wireless port (e.g., an IR or RF port) or a wired port (e.g., a serial port). The controller  1805 ,  1605  receives the blood glucose data via the communication port  1635  from a separate device (e.g., a blood glucose monitor). The controller  1805 ,  1605  adjusts the blood glucose testing times by communicating a new testing time via the communication to the separate device, or by providing a prompt for the user to initiate a blood glucose test using the separate device. 
     In some embodiments, the device  1800  includes a blood glucose monitor  1837  communicatively coupled to the input  1820 . The device  1800  receives blood glucose data, via the input  1820 , from the blood glucose monitor  1837 . In some embodiments, controller  1805  adjusts the blood glucose testing times by generating a prompt to the user to initiate a blood glucose measurement using the blood glucose monitor. 
       FIG. 19  is a flow diagram of portions of method  1900  to automatically determine blood glucose testing times for an insulin pump user. At block  1905 , blood glucose data of a user of an insulin pump is received into a blood glucose (BG) management device. In some embodiments, the BG management device includes an insulin pump. In some embodiments, the BG management device includes a blood glucose monitor. The blood glucose data is obtained from the user during a number of specified blood glucose testing times. 
     At block  1910 , the BG management device calculates a measure of blood glucose level variability from the blood glucose data. Examples of the variability measurement include a standard deviation of the blood glucose data, an average deviation of the blood glucose data, a variance of the blood glucose data, a range of the blood glucose data, or combinations of the variability measurements. 
     At block  1915 , the BG management device adjusts a blood glucose testing time in response to the measure of blood glucose variability. In some embodiments, the BG management device adjusts a testing time by generating a prompt to initiate testing at an adjusted time. In some embodiments, the BG management device adjusts a testing time by communicating a prompt to initiate a test or measurement to a blood glucose monitor included in the BG management device or included in separate device. 
     If the blood glucose testing times determined by the BG management device become statistically significant over time, the BG management device helps a patient obtain a better view of their overall blood glucose control. 
     The above detailed description includes references to the accompanying drawings, which form a part of the detailed description. The drawings show, by way of illustration, specific embodiments in which the invention can be practiced. These embodiments are also referred to herein as “examples.” All publications, patents, and patent documents referred to in this document are incorporated by reference herein in their entirety, as though individually incorporated by reference. In the event of inconsistent usages between this document and those documents so incorporated by reference, the usage in the incorporated reference(s) should be considered supplementary to that of this document; for irreconcilable inconsistencies, the usage in this document controls. 
     In this document, the terms “a” or “an” are used, as is common in patent documents, to include one or more than one. In this document, the term “or” is used to refer to a nonexclusive or, such that “A or B” includes “A but not B,” “B but not A,” and “A and B,” unless otherwise indicated. 
     It is to be understood that the above description is intended to be illustrative, and not restrictive. For example, the above-described embodiments (and/or aspects thereof) may be used in combination with each other. Many other embodiments will be apparent to those of skill in the art upon reviewing the above description. The scope of the invention should, therefore, be determined with reference to the appended claims, along with the full scope of equivalents to which such claims are entitled. In the appended claims, the terms “including” and “in which” are used as the plain-English equivalents of the respective terms “comprising” and “wherein.” Also, in the following claims, the terms “including” and “comprising” are open-ended, that is, a system, device, article, or process that includes elements in addition to those listed after such a term in a claim are still deemed to fall within the scope of that claim. Moreover, in the following claims, the terms “first,” “second,” and “third,” etc. are used merely as labels, and are not intended to impose numerical requirements on their objects. 
     The Abstract of the Disclosure is provided to comply with 37 C.F.R. § 1.72(b), requiring an abstract that will allow the reader to quickly ascertain the nature of the technical disclosure. It is submitted with the understanding that it will not be used to interpret or limit the scope or meaning of the claims. In addition, in the foregoing Detailed Description, it can be seen that various features are grouped together in a single embodiment for the purpose of streamlining the disclosure. This method of disclosure is not to be interpreted as reflecting an intention that the claimed embodiments require more features than are expressly recited in each claim. Rather, as the following claims reflect, inventive subject matter lies in less than all features of a single disclosed embodiment. Thus the following claims are hereby incorporated into the Detailed Description, with each claim standing on its own.