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A Nationwide Chronic Disease Management Solution via Clinical Decision Support Services: Software Development and

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Area of Science:

  • Health Informatics
  • Public Health
  • Digital Health

Background:

  • Rising demand for healthcare services due to an aging population and chronic diseases.
  • Need for person-centered integrated care models for chronic disease management.
  • Turkish Ministry of Health's initiative to implement an integrated health care model.

Purpose of the Study:

  • Present the design, development, and nationwide implementation of the national Disease Management Platform (DMP).
  • Address challenges in interoperability, clinical workflow integration, and user-friendliness.
  • Demonstrate the platform's scalability, performance, and adaptability.

Main Methods:

  • Integrated care solution utilizing clinical decision support services.
  • Adherence to evidence-based clinical guidelines for screening and management.
  • Integration with existing health IT systems using international standards (HL7 FHIR).
  • Co-creation strategy for developing disease modules and ensuring ease of use.
  • Horizontal scalability for high performance under load.

Main Results:

  • Nationwide implementation serving 25,568 health professionals and 16,058,904 citizens as of September 2023.
  • Facilitated 73,715,269 patient encounters for chronic disease screening and monitoring.
  • Diagnosed 3,545,573 with obesity, 534,423 with high cardiovascular risk, 490,346 with diabetes, and 144,768 with hypertension.

Conclusions:

  • The DMP demonstrates horizontal scalability and efficient service delivery to thousands of practitioners.
  • Seamless interoperability with existing health IT solutions and integration into clinical workflows.
  • Maximizes evidence-based decision support through integration with point-of-care EHR systems.
  • Adaptable for deployment in other regional and national settings due to international standards.
  • Operational since January 2020, effectively coordinating chronic disease management nationwide.