Research And Implementation Of Digital Chronic Disease Management System

Chronic disease is a blanket term for a group of disorders characterized by long term,non-infection,and incurability.In order to meet the complex care needs of chronic disease patients,an innovative patient-centered healthcare service called ”chronic disease management” began to emerge gradually and continue to develop since the 1980 s.The key characteristic of chronic disease management that differs from traditional healthcare service is integrated care,which aims at providing patients with organized and coordinated medical services.In recent years,the rapid development of information technology represented by mobile health and artificial in-telligence has promoted the transition of chronic disease management from traditional methods to comprehensive digital methods,which assisted in the formulation of closed-loop feedback between patients and care providers,as well as the integration of evidenced-based knowledge and information contained in the data into the management procedures.Although the chronic disease management theoretical model represented by CCM has been validated by a huge number of implementation researches in many countries,there still exist a series of key challenges in the current practice of chronic disease management in China,which result in a significant gap between standards of care and medical practice in the digital context.Moreover,several limitations exist in the current implementation studies of digital chronic dis-ease management.This thesis systematically studies key methods for digital chronic manage-ment in China to address the above key issues.The concrete contents are as follows:(1)Construction and representation of an e Health-based integrated care model.To address the challenges in terms of division of responsibilities among care providers and lack of com-prehensive decision support in the digital context,this thesis first uses pathway to formalize the universal chronic disease management method in a clear and executable manner.Through analysis of several guidelines for the three common chronic diseases(hypertension,diabetes,and COPD),a universal care pathway consisting of nine common tasks has been proposed,and three concrete care pathways for the three diseases have been specified in the digital context.Based on the proposed care pathway,this thesis further constructs an individual-scale theoreti-cal model for the management mode in China called Pathway-driven e Health-based Integrated Care Model(PEICM),and represents the structural information and medical knowledge con-tained in the model using ontology combined with semantic rules.(2)Personalized methods for improvement of patient compliance in the digital context.To address the challenges in terms of patient self-management compliance as well as limitations in related personalization studies,this thesis first constructs a user model concerned with pa-tient compliance based on the user modeling process in the goal-directed design method.Three types of user personas and their corresponding goals(needs)have been identified for further functional design of m Health app.On the other hand,this thesis explores the feasibility of ap-plying data-driven artificial intelligence technology in strengthening pathway tasks to be more personalized.Concretely,two sub-studies have been performed,including personalized health education based on patient health data using knowledge-based health recommender system and several natural language processing techniques,and personalized management strategy gener-ation based on status of patients and care providers using reinforcement learning in the virtual management environment.(3)Design and implementation of a closed-loop digital chronic disease management sys-tem.To address the challenges in terms of system implementation(e.g.,lack of theoretical sup-port and disease integration),this thesis designs and implements a closed-loop digital chronic disease management system based on the proposed model(PEICM).The system consists of two main components: a service engine for data storage and decision support,and clients for care providers and patients.Concretely,the service engine is a web service deployed on the cloud server,interacting with clients via several types of APIs.The core of the engine is the constructed Universal Care Pathway Ontology(UCPO).The client for care providers is de-signed based on the common pathway tasks,which can help care providers monitor patients and perform the coordinated management.The client for patents is designed based on the identified personalized needs and behaviour change wheels,which can provide comprehensive self-management support for patients and improve their compliance to a certain extent.The implemented system has been deployed in several regions of China.(4)Establishment and practical test for an evaluation model of digital chronic manage-ment.To address the challenges in terms of system evaluation,this thesis refines an individual-level evaluation model consisting of three dimensions(focus,perspective,and role)for digital chronic disease management based on the evaluation model for telemedicine.According to the proposed evaluation framework,the implemented system has been evaluated in practice with different levels of evidence,including retrospective analysis based on long-term system observational data,single-arm quasi-experimental study for COPD patients,and randomized controlled trial for hypertension patients.The evaluation results show that the system can im-plement closed-loop collaborative management with efficient communication between patients and care providers,meanwhile improve patients’ disease control,quality of life,and disease awareness to a certain extent.In conclusion,the pathway-driven digital chronic disease management system proposed in this thesis can address several issues in related studies and the management practice in China to a certain extent,providing theoretical guidance and practical validation for large-scale promotion and application of digital chronic disease management in China.