Toward Standardized Monitoring of Patients With Chronic Diseases in Primary Care Using Electronic Medical Records:...

Long-term care for patients with chronic diseases poses a huge challenge in primary care. There are deficits in care, especially regarding monitoring and creating structured follow-ups. Appropriate electronic medical records (EMR) could support this, but so far, no generic evidence-based template exists.

The aim of this study is to develop an evidence-based standardized, generic template that improves the monitoring of patients with chronic conditions in primary care by means of an EMR.

We used an adapted Delphi procedure to evaluate a structured set of evidence-based monitoring indicators for 5 highly prevalent chronic diseases (ie, diabetes mellitus type 2, asthma, arterial hypertension, chronic heart failure, and osteoarthritis). We assessed the indicators' utility in practice and summarized them into a user-friendly layout.

This multistep procedure resulted in a monitoring tool consisting of condensed sets of indicators, which were divided into sublayers to maximize ergonomics. A cockpit serves as an overview of fixed goals and a set of procedures to facilitate disease management. An additional tab contains information on nondisease-specific indicators such as allergies and vital signs.

Our generic template systematically integrates the existing scientific evidence for the standardized long-term monitoring of chronic conditions. It contains a user-friendly and clinically sensible layout. This template can improve the care for patients with chronic diseases when using EMRs in primary care.