Phanareth Klaus, Vingtoft Søren, Christensen Anders Skovbo, Nielsen Jakob Sylvest, Svenstrup Jørgen, Berntsen Gro Karine Rosvold, Newman Stanton Peter, Kayser Lars
Department of Internal Medicine Q, Bispebjerg, Frederiksberg University Hospital, Copenhagen, Denmark.
Aalborg University, Aalborg, Denmark.
JMIR Res Protoc. 2017 Jan 16;6(1):e6. doi: 10.2196/resprot.6506.
There is worldwide recognition that the future provision of health care requires a reorganization of provision of care, with increased empowerment and engagement of patients, along with skilled health professionals delivering services that are coordinated across sectors and organizations that provide health care. Technology may be a way to enable the creation of a coherent, cocreative, person-centered method to provide health care for individuals with one or more long-term conditions (LTCs). It remains to be determined how a new care model can be introduced that supports the intentions of the World Health Organization (WHO) to have integrated people-centered care.
To design, pilot, and test feasibility of a model of health care for people with LTCs based on a cocreative, iterative, and stepwise process in a way that recognizes the need for person-centered care, and embraces the use of digital technology.
The overall research method was inspired by action research and used an agile, iterative approach. In 2012, a living lab was established in a Danish municipality which allowed for the freedom of redesigning health care processes. As the first step, a wide group of stakeholders was gathered to create a layout for the reorganization of services and development of technology, based on established principles for innovative management of people with chronic conditions. The next three steps were (1) a proof of concept in 2012, (2) a pilot study, and (3) a feasibility study from 2013 to 2015, in which a total of 93 chronic obstructive pulmonary disease (COPD) patients were enrolled. Citizens were provided a tablet-based solution for remote follow-up and communication purposes, and access to a 24/7 response and coordination center that coordinated both virtual and face-to-face support for COPD management. In step five the initial model was extended with elements that support continuity of care. Beginning in the autumn of 2013, 1102 frail elderly individuals were included and offered two additional services: an outgoing acute medical team and a local subacute bed function.
Based on the findings from the iterative process, and evolving technology and workflow solutions, we propose a robust and feasible model that can provide a framework for developing solutions to support an active life with one or more LTCs. The resulting Epital Care Model (ECM) consists of six stages, and serves as a template for how a digitally-enhanced health service can be provided based on patients' medical needs. The model is designed to be a proactive, preventive, and monitoring health care system that involves individuals in the management of their own health conditions.
The ECM is in accordance with WHO's framework for integrated people-centered health services, and may serve as a framework for the development of new technologies and provide a template for future reorganization.
全世界都认识到，未来的医疗保健服务需要重新组织护理服务，增强患者的自主权和参与度，同时需要技术娴熟的医疗专业人员提供跨部门和跨组织协调的医疗服务。技术可能是创建一种连贯、共创、以人为本的方法，为患有一种或多种长期疾病（LTC）的个人提供医疗保健服务的途径。如何引入一种新的护理模式以支持世界卫生组织（WHO）以患者为中心的综合护理的意图，仍有待确定。
设计、试点并测试一种基于共创、迭代和逐步过程的针对患有长期疾病的人群的医疗保健模式的可行性，该模式要认识到以患者为中心的护理的必要性，并采用数字技术。
总体研究方法受行动研究启发并采用敏捷、迭代的方法。2012年，在丹麦的一个自治市建立了一个生活实验室，以便能够自由重新设计医疗保健流程。第一步，召集了广泛的利益相关者群体，根据慢性病患者创新管理的既定原则，为服务重组和技术开发创建一个布局。接下来的三个步骤是：（1）2012年进行概念验证；（2）进行一项试点研究；（3）2013年至2015年进行一项可行性研究，共招募了93名慢性阻塞性肺疾病（COPD）患者。为市民提供了基于平板电脑的远程随访和沟通解决方案，并接入一个全天候响应和协调中心，该中心协调对COPD管理的虚拟和面对面支持。在第五步，初始模型扩展了支持连续护理的要素。从2013年秋季开始，纳入了1102名体弱老年人，并提供了另外两项服务：一个出诊急性医疗队和一个当地亚急性床位功能。
基于迭代过程的结果、不断发展的技术和工作流程解决方案，我们提出了一个强大且可行的模型，该模型可为开发支持患有一种或多种长期疾病的人积极生活的解决方案提供框架。由此产生的Epital护理模式（ECM）由六个阶段组成，并作为基于患者医疗需求提供数字化增强型医疗服务的模板。该模型旨在成为一个主动、预防和监测的医疗保健系统，让个人参与自身健康状况的管理。
ECM符合WHO以患者为中心的综合医疗服务框架，可作为新技术开发的框架，并为未来的重组提供模板。
