E-Health Approach to Chronic Disease Management for Self-Management and Behaviour Change

  • Zrimec T
  • Beštek M
  • Cukjati I
  • et al.
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Background: The WHO estimates that chronic diseases cause at least 60% of deaths annually. The treatment of patients with chronic diseases is therefore becoming one of the most important areas of research. The good news is that approximately 70-80% of patients with chronic conditions can be managed with supported self-care. Modern disease management models increasingly include mobile technologies and ICT tools for facilitating self care programs and programs for behaviour change. The number of E-health applications that enable the user to become an active and responsible partner for his own health and care pathway is increasing. However, small number has gone through randomized clinical trials (RCT) for evaluation of their success. Objective: To develop innovative E-health application that will enable successful self-management of chronic diseases and will influence user behaviour. To clinically evaluate the success of the application via randomized control trials (RCT). Methods: The project consisted of three key phases: definition of an intervention by clinical knowledge modelling using OpenEHR technology, application design and development using BPM business process modelling (BPM) and service oriented architecture (SOA), and evaluation of each e-health application outcome by RCT. The Clinical Knowledge modelling phase included: - defining which parameters to be measured by the patient, how often, as well as the number and the timing of the alerts and reminders - selection of questioners for assessing patient condition, mood and satisfaction, and - defining outcome measures for judging the success of a particular disease management. The application is designed as a set of concurrent processes that are direct mapping of the disease care protocol of a particular chronic disease. The E-health application is patient centred. It supports multiple user roles and activities including patients, medical professionals and relatives. The main goal regarding patients is to achieve patient empowerment. Consequently, the E-health application contains a number of tools including: self-care support, decision making aids, disease specific and general health education, communication with health care professionals. Similar set of tools is available for medical professionals for monitoring, controlling, coordinating and supervising the care plans of their patients. Results: The E-health application for supporting self-management of two chronic diseases, Asthma and Diabetes type II, was implemented. Randomized control trials were designed and approved by the Ethic Committee. RCT for Asthma is currently running and RCT for Diabetes is ready to start. Conclusions: The main goal of an E-health chronic disease management is to enable patient empowerment for successful self-management and behavior change. This empowerment is absolutely necessary if we want to achieve effective chronic disease management, which can improve health outcome and can increase quality of life. By providing innovative tools for showing patients current health status in the form of informative graphical and numerical representations, as well as access to the whole health status history can result in behavior change.




Zrimec, T., Beštek, M., Cukjati, I., Šuškovič, S., Kurent, B., & Brodnik, A. (2012). E-Health Approach to Chronic Disease Management for Self-Management and Behaviour Change. In Medicine 2.0.

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