Bae Ye Seul, Park Seoyeon, Noh Changbo, Choi Boram, Yi Seung Ah, Kim So Eun, Kim Yoon Ji, Kang Jae-Heon
Big Data Research Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
Department of Family Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
Digit Health. 2025 May 23;11:20552076251344375. doi: 10.1177/20552076251344375. eCollection 2025 Jan-Dec.
Hypertension and diabetes are typically managed in primary care settings, where continuous and tailored care based on continuity in daily life is essential to improve health outcomes.
To address the shortage of human and material resources in primary care and to enhance health outcomes, we developed and implemented a comprehensive digital medicine platform in a real-world setting.
A patient application (app) and a web app for healthcare providers were developed to enable bidirectional communication between patients and healthcare providers. Primary physicians and care coordinators utilized this platform to deliver personalized care management. To manage multiple patients with limited staff, automated message generation logic was used.
Using the app, patients could self-measure blood pressure and blood glucose level, receive feedback from healthcare providers, and obtain personalized medication management, disease education, and lifestyle guidance regarding smoking, alcohol consumption, and exercise. Healthcare providers can view the data generated by the patient app, in real time, on the web app, and immediately send messages when an action is required. An evaluation of effectiveness was conducted with 502 patients in the intervention group and 502 patients in the control group over a 24-week intervention. In the intervention group, systolic blood pressure decreased by 3.8% ( < 0.001), diastolic blood pressure by 3.4% ( < 0.001), body mass index by 1.6% ( < 0.001), and waist circumference by 1.5% ( < 0.001). HDL cholesterol increased by 2.4% ( < 0.05), and triglycerides decreased by 5.4% ( < 0.05).
This study demonstrated that the adoption of a digital medicine platform is effective and essential for continuous patient management in primary care. Information and communications technology-based tools and applications are becoming increasingly important in healthcare, and our study has provided valuable insights into the management of chronic diseases.
高血压和糖尿病通常在基层医疗环境中进行管理，在这种环境下，基于日常生活连续性的持续且个性化的护理对于改善健康结果至关重要。
为了解决基层医疗中人力和物力资源短缺的问题并提高健康结果，我们在实际环境中开发并实施了一个综合数字医学平台。
开发了一个患者应用程序（app）和一个供医疗服务提供者使用的网络应用程序，以实现患者与医疗服务提供者之间的双向沟通。初级医师和护理协调员利用这个平台提供个性化的护理管理。为了在人员有限的情况下管理多名患者，使用了自动消息生成逻辑。
通过该应用程序，患者可以自行测量血压和血糖水平，接收医疗服务提供者的反馈，并获得个性化的药物管理、疾病教育以及关于吸烟、饮酒和运动的生活方式指导。医疗服务提供者可以在网络应用程序上实时查看患者应用程序生成的数据，并在需要采取行动时立即发送消息。在为期24周的干预期间，对干预组的502名患者和对照组的502名患者进行了有效性评估。干预组的收缩压下降了3.8%（<0.001），舒张压下降了3.4%（<0.001），体重指数下降了1.6%（<0.001），腰围下降了1.5%（<0.001）。高密度脂蛋白胆固醇升高了2.4%（<0.05），甘油三酯下降了5.4%（<0.05）。
本研究表明，采用数字医学平台对于基层医疗中持续的患者管理是有效且必不可少的。基于信息和通信技术的工具及应用在医疗保健中变得越来越重要，我们的研究为慢性病管理提供了有价值的见解。
