Many experts have called for the redesign of primary care to better serve patients with chronic disease. Chronic disease performance measures as well as patient and provider satisfaction will improve as health care systems address the following three issues: 1) the limitations of infrequently-occurring, provider-driven 20-minute visits;2) medication non-adherence;3) patient self-management for chronic conditions. The long-standing paradigm of chronic disease management through the standard provider-driven 20 minute visit, which may occur every 3 months at best in indigent populations, does not support the patients need to manage their diseases on a daily basis. Multiple competing priorities leave both the patient and the provider dissatisfied. The challenges of chronic disease management are exacerbated in the cases of """"""""complex"""""""" patients who have multiple, comorbid chronic conditions. Traditional chronic disease management strategies take a """"""""silo approach"""""""" in their focus on a single condition, and are not best designed to take into account disease treatments for one condition that may potentially be in conflict with treatments for another, coexisting chronic condition. The creation of an infrastructure to enable the study of chronic disease interventions that target at-risk patients and offer personalized support outside of clinic visits is essential to the advancement of chronic disease management in these three areas. This project proposes to both build data capacity for research by supporting the integration of patient-provided data into the legal electronic medical record and facilitating linked access to multiple clinical data sets within a data warehouse and to improve targeted and personalized outreach to complex patients with comorbid chronic diseases such as diabetes, mental health disorders, HIV, and cardiovascular disorders.
Traditional single-condition approaches to chronic disease management are not best designed to take into account conflicting treatments for """"""""complex"""""""" patients who have multiple chronic conditions such as diabetes, hyperlipidemia, depression, and hypertension. Better infrastructure for research capacity to improve health care for complex patients is essential to the advancement of chronic disease management.