A Collaborative Platform for Management of Chronic Diseases via Guideline-Driven Individualized Care Plans

Abstract

Older age is associated with an increased accumulation of multiple chronic conditions. The clinical management of patients suffering from multiple chronic conditions is very complex, disconnected and time-consuming with the traditional care settings. Integrated care is a means to address the growing demand for improved patient experience and health outcomes of multimorbid and long-term care patients. Care planning is a prevalent approach of integrated care, where the aim is to deliver more personalized and targeted care creating shared care plans by clearly articulating the role of each provider and patient in the care process. In this paper, we present a method and corresponding implementation of a semi-automatic care plan management tool, integrated with clinical decision support services which can seamlessly access and assess the electronic health records (EHRs) of the patient in comparison with evidence based clinical guidelines to suggest personalized recommendations for goals and interventions to be added to the individualized care plans. We also report the results of usability studies carried out in four pilot sites by patients and clinicians.

Pathway-Driven Coordinated Telehealth System for Management of Patients With Single or Multiple Chronic Diseases in China: System Development and Retrospective Study

“…Among these studies, three ( [16,17] and our study) utilized ontology to provide decision support abilities during the care process. Four of the studies ( [16][17][18] and ours) supported the management of MCC through different mechanisms. Three studies ( [18,19] and ours) designed an individual platform for both care providers and patients, respectively.…”

“…Four of the studies ( [16][17][18] and ours) supported the management of MCC through different mechanisms. Three studies ( [18,19] and ours) designed an individual platform for both care providers and patients, respectively. In terms of evaluation, Riaño et al [16], Lasierra et al [17], and Laleci et al [18] only performed a technical evaluation or pilot application on their solutions, whereas Omboni et al [19] and our study deployed the system in a real-world setting for a relatively long period to test the effectiveness.…”

“…Patient self-monitoring at home and remote guidance from care providers can be realized with the assistance of telehealth systems [15]. However, most of these systems focus on a single chronic disease, and few studies have attempted to integrate multiple types of chronic diseases into one system [16][17][18][19]. A telehealth system designed for managing multiple chronic illnesses simultaneously can not only support the management of patients with MCC but can also reduce the cost of developing multiple telehealth systems for managing different chronic diseases.…”

A Method for Machine Learning Generation of Realistic Synthetic Datasets for Validating Healthcare Applications

“…Context A: Scenarios of use: The main scenario was the validation of clinical decision support applications, providing recommendations to patients or healthcare professionals [29]. The scope encompassed both primary and secondary care.…”

Evaluation of patient perception towards dynamic health data sharing using blockchain based digital consent with the Dovetail digital consent application: A cross sectional exploratory study

“…Such services typically combine data from multiple sources, which can be used to inform patients, support self-management, and show to healthcare practitioners a more complete picture. 3 Management of health data is a rapidly growing challenge worldwide. A global increase in smart healthcare, telecare and telehealth, means that there is a shift toward digital health data on a significant scale, which will eventually result in growing amounts of shared data.…”