Discipline of Orthopaedics & Trauma, University of Adelaide, Level 5G 584, Royal Adelaide Hospital, Port Road Adelaide, South Australia, Australia 5000.
School of Computer Science, University of Adelaide, Adelaide, Australia.
Bull World Health Organ. 2020 Aug 1;98(8):569-575. doi: 10.2471/BLT.19.249136. Epub 2020 Jun 2.
Multimorbidity is the presence of more than one chronic disease condition in an individual. Health-related, socioeconomic, cultural and environmental factors, as well as patient behaviour, all influence the outcomes of multimorbidity. Addressing these complex and often interacting biopsychosocial factors therefore requires a shift in treatment from a physical damage model towards person-centred integrated care with increased patient agency. Education influences behaviour and can be used to empower patients and their carers with greater agency, thus allowing greater responsibility for and control over the management of patient care. In this paper we reflect on our own learning as a community of health practitioners from different disciplines. Recognizing the increasing importance of patient agency in driving the evolution of health care, we describe the concept of a web-based personal digital health hub for integrated patient care. Informed by collaboration between patient, health and education communities, we share our early experience in the implementation of a health hub around a cohort of patients with hip fractures. We also describe a vision for future health care based on the co-creation of digital health hubs centred on patients' and carers' needs. The health hub could allow important advances and efficiencies to be achieved in workforce practice and education; patient and carer engagement in self-care; and the collection of patient-reported health data required for ongoing research and improvements in health care.
多发病是指个体同时存在多种慢性疾病。健康相关、社会经济、文化和环境因素以及患者行为都会影响多发病的结局。因此，要解决这些复杂且往往相互作用的生物心理社会因素，就需要将治疗从针对身体损伤的模式转变为以患者为中心的综合关怀，增强患者的能动性。教育会影响行为，可以用来增强患者及其照护者的能动性，从而让他们对患者护理的管理承担更多责任并进行更好的控制。在本文中，我们作为来自不同学科的卫生保健从业者共同体，反思了我们自己的学习经历。认识到患者能动性在推动医疗保健发展方面的重要性日益增加，我们描述了一个基于网络的个人数字健康中心的概念，用于整合患者护理。在患者、健康和教育界别的合作基础上，我们分享了在围绕一组髋部骨折患者实施健康中心方面的早期经验。我们还描述了基于以患者和照护者的需求为中心的数字健康中心共同创建的未来医疗保健愿景。健康中心可以在劳动力实践和教育方面取得重要进展和提高效率；患者和照护者参与自我护理；并收集持续研究和改进医疗保健所需的患者报告的健康数据。
