JMIR Publications

ABSTRACT

Background:

Integrated care enhanced with information technology has emerged as a means to transform health services to meet long-term care needs of chronic disease patients. However, the feasibility of applying integrated care to the emerging “three-manager” mode in China remains to be explored. Moreover, only few studies attempted to integrate multiple types of chronic diseases into one system.

Objective:

This study aimed to present a coordinated telehealth system that supports the management of single or multiple chronic diseases, meanwhile addresses the existing challenges of “three-manager” mode in China.

Methods:

The system was designed based on a tailored integrated care model. The model was constructed from an individual scale, mainly concentrating on specifying the management roles and their responsibilities through a universal care pathway. A custom ontology was developed to represent the knowledge contained in the model. The system consisted of a service engine for data storage and decision support, as well as different forms of clients for care providers and patients. Currently, the system supports management of three single chronic diseases (hypertension, type 2 diabetes mellitus, and chronic obstructive pulmonary disease) and one type of multiple chronic conditions (hypertension with type 2 diabetes mellitus). A retrospective study was performed based on the long-term observational data extracted from the system to analyze system usability, treatment effect, and quality of care.

Results:

The retrospective analysis involved 6,964 chronic disease patients and 249 care providers who have registered in our system since the deployment in 2015. A total of 519,598 self-monitoring records have been submitted by the patients. The engine was able to generate different types of records regularly according to the specific care pathway. Based on the comparison tests and casual inference results, a part of patient outcomes improved after receiving intervention through the system, especially the systolic blood pressure of hypertensive patients (P<.001 in all comparison tests and an approximately 5 mmHg decrease after intervention via causal inference). The regional case study shows that the work efficiency of care providers differed individually.

Conclusions:

Our system has the potential to provide effective management support for single or multiple chronic conditions simultaneously. The tailored closed-loop care pathway was feasible and effective under the “three-manager” mode in China. One direction for future work is to introduce advanced artificial intelligence techniques to construct a more personalized care pathway.