Meeting Minutes

What follows are minutes of the first Nightscout FDA Pre-submission Meeting which took place on October 8, 2014.


  • FDA expressed interest in a continuing conversation related to the Nightscout project
  • While Medical Device regulations are applicable to the Nightscout project, Medical device requirements are implemented to ensure patient safety and were written to be flexible to address all types of medical devices and device manufacturers. How these regulations can be met was discussed with the agency.
  • Areas to be discussed – is there one responsible party? -
  • How are design controls met during software development?
  • How to fulfill post market requirements?
  • What product claims are made?
  • How are data security and privacy handled?
  • FDA and Nightscout project members discussed performing a gap analysis regarding the regulations for the next discussion. Meeting time TBD.


Participant introductions of attendees:

CGM in the Cloud / Nightscout

John Costik, Ping Fang, Ben West, and Scott Leibrand

Your Diabetes May Vary

Bennet Dunlap

Invited guests

Medtronic: Mark O’Donnell


Beth Stephen, Don St. Pierre, Robert Sauer, Stayce Beck, Courtney Lias, Katherine Serrano, Suzanne Schwartz, and Ariel Seeley

Discussion Topics

Introduction: FDA requested some background discussion on Nightscout’s software and project, history, open-source development methodology, and some existing controls, including general project oversight, how system updates are handled, and directions available to users.

FDA provided some initial comments to emphasize that FDA doesn’t have a bias against the open source route, nor is Nightscout the first time FDA has seen open source software. FDA emphasized that a key tenet of device regulation is that some entity be responsible for assuring the safety and effectiveness of the device and that postmarket safety is adequately monitored and that any potential problems are adequately addressed. FDA further emphasized that the requirements for medical devices were implemented to ensure patient safety and were written to be flexible to address all types of medical devices and device makers, and that FDA believes it is acheivable for Nightscout to meet applicable requirements even with non-traditional methods of development.

FDA asked questions about Nightscout’s current processes and how/whether they currently control software versions that go out to general use of Nightscout. Further questions were discussed about how Nightscout handles topics that should be addressed in device development, including quality, safety, and responsibility (e.g. Design Controls, Change Controls, Postmarket Surveillance, Claims, and Data/Cybersecurity) were also discussed. Nightscout provided a description of how core developers maintain the main community version, and review and test new features before they are incoportated or distributed to end users. Nightscout used an example of a current issue of incorrect time values to address questions such as:

  • How quickly are changes/problems addressed?
    • Determined by interest of developers and safety concerns
  • How is information on updates distributed?
    • Currently an informal process for development updates and checking
  • Who is responsible for code updates?
    • Ben currently triages, is the source code curator, coordinates efforts between developers. This activity is currently voluntary and informal.
  • How are updates tracked?
    • Website can track which version people are using, can push update requests to users.

The group discussed the FDA’s and and Nightscout’s shared goal of safety. The FDA hears the demand from patients for devices like Nightscout to exist, and doesn’t have a particular problem with safe and effective devices of this kind coming to market. In fact, they want to make this happen faster.

The FDA also recognizes the need for device interoperability to improve data access, along the lines of what Tidepool is working on. They noted recent progress on interoperability from CGM makers. Subsequent to the meeting, the FDA would like to hear from our community to help make sure interoperability moves forward.

The group discussed FDA’s desire that there be a single responsible party to ensure that nothing falls through the cracks. The FDA emphasized the need for one party to take responsibility. For example, change control to determine when updates were ready to be implemented to general users, what problems need to be addressed and on what timeline, etc. should be adequately addressed. The FDA also asked about how problems are identified, reported, and addressed. They want to make sure there is a mechanism to handle, triage, and prioritize the response to complaints that might affect safety, to ensure that fixes can be distributed to people using the system, and to make sure that Nightscout is preventing unexpected complications from modifications. Nightscout stated that currently, how quickly a problem is addressed is determined by how quickly a developer picks up the issue and propose a solution. This may depend on the interest of the developers, the safety concern raised, and the complexity of the issue and its solution. The FDA discussed the benefits of implementing a process for evaluating the severity of issues and tailoring the speed at which solutions are developed to address the relative risk associated with the particular scenario. The FDA recognizes that Nightscout’s existing methods and processes, while informal, appear to address some of these concerns, but would like to see further documentation of how Nightscout is doing so, and wants to ensure that there is someone ultimately responsible. FDA interests include what happens if developers do not “jump” in quickly enough to develop solutions, the need to track issue severity, and concerns regarding the importance of reporting problems. Nightscout noted that they had determined that one person needed to be assigned as the lead. Ben West was voted by the core contributors to be the source code curator. FDA noted that was encouraging and that a similar approach could be more broadly implemented to address some of the FDA’s safety and regulatory concerns.

The group discussed how Nightscout might be able to provide the FDA with better visibility into any events that affect patient safety. The FDA would welcome submissions from Nightscout to MedWatch, especially if they can include as much detail as possible to see what was really going on. Such processes will help Nightscout make decisions on how to improve the system.

FDA requested that Nightscout begin working on a gap analysis to document what is already being covered, and which areas require improvements to come into compliance. The FDA requested a follow-up meeting with Nightscout within a few months.