Laleci Erturkmen Gokce B, Yuksel Mustafa, Sarigul Bunyamin, Arvanitis Theodoros N, Lindman Pontus, Chen Rong, Zhao Lei, Sadou Eric, Bouaud Jacques, Traore Lamine, Teoman Alper, Lim Choi Keung Sarah N, Despotou George, de Manuel Esteban, Verdoy Dolores, de Blas Antonio, Gonzalez Nicolas, Lilja Mikael, von Tottleben Malte, Beach Marie, Marguerie Christopher, Klein Gunnar O, Kalra Dipak
SRDC Software Research Development and Consultancy Corp, Ankara, Turkey.
Institute of Digital Healthcare, WMG, University of Warwick, Coventry, UK.
Comput Struct Biotechnol J. 2019 Jun 12;17:869-885. doi: 10.1016/j.csbj.2019.06.003. eCollection 2019.
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.
高龄与多种慢性病的累积增加有关。患有多种慢性病的患者的临床管理在传统护理环境中非常复杂、脱节且耗时。综合护理是一种满足对改善多病共存和长期护理患者的患者体验及健康结果日益增长的需求的手段。护理计划是综合护理的一种普遍方法，其目的是通过明确阐述每个提供者和患者在护理过程中的作用，制定共享护理计划，提供更个性化和有针对性的护理。在本文中，我们介绍了一种半自动护理计划管理工具的方法及相应实现，该工具与临床决策支持服务集成，可与基于证据的临床指南相比，无缝访问和评估患者的电子健康记录（EHR），以建议添加到个性化护理计划中的目标和干预措施的个性化建议。我们还报告了在四个试点地点由患者和临床医生进行的可用性研究结果。
