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Synergy-COPD: a systems approach for understanding and managing chronic diseases.

Gomez-Cabrero D, Lluch-Ariet M, Tegnér J, Cascante M, Miralles F, Roca J, Synergy-COPD consorti - J Transl Med (2014)

Bottom Line: The challenges posed by the epidemics of CD have triggered a novel health paradigm with major consequences on the traditional concept of disease and with a profound impact on key aspects of healthcare systems.The current manuscript describes main features of the project design and the strategies put in place for its development, as well the expected outcomes during the project life-span.Moreover, the manuscript serves as introductory and unifying chapter of the different papers associated to the Supplement describing the characteristics, tools and the objectives of Synergy-COPD.

View Article: PubMed Central - HTML - PubMed

ABSTRACT
Chronic diseases (CD) are generating a dramatic societal burden worldwide that is expected to persist over the next decades. The challenges posed by the epidemics of CD have triggered a novel health paradigm with major consequences on the traditional concept of disease and with a profound impact on key aspects of healthcare systems. We hypothesized that the development of a systems approach to understand CD together with the generation of an ecosystem to transfer the acquired knowledge into the novel healthcare scenario may contribute to a cost-effective enhancement of health outcomes. To this end, we designed the Synergy-COPD project wherein the heterogeneity of chronic obstructive pulmonary disease (COPD) was addressed as a use case representative of CD. The current manuscript describes main features of the project design and the strategies put in place for its development, as well the expected outcomes during the project life-span. Moreover, the manuscript serves as introductory and unifying chapter of the different papers associated to the Supplement describing the characteristics, tools and the objectives of Synergy-COPD.

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Workflow for an Integrated Care Service (ICS) management and execution. The patient is allocated into an ICS defined as a set of well standardized tasks to be carried out on the basis of his/her health condition and social circumstances to achieve target objectives aligned with the comprehensive treatment plan. Two differential ICS characteristics, as compared to usual care, are the patient-centered approach and the longitudinal nature of the interventions which length depends on the type of ICS. The corresponding ICS template is used as a library of resources for the correct customization and execution of the ICS workflow. Integration with corporate Electronic Health Record (EHR) allows instant access to required patient information for case identification and evaluation, avoid data duplicity and preserve the current corporate clinical data chain of custody. Follow-up and discharge reports can also be sent to the corporate EHR to keep trace of the ICS execution as part of the patient clinical episodes.
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Figure 2: Workflow for an Integrated Care Service (ICS) management and execution. The patient is allocated into an ICS defined as a set of well standardized tasks to be carried out on the basis of his/her health condition and social circumstances to achieve target objectives aligned with the comprehensive treatment plan. Two differential ICS characteristics, as compared to usual care, are the patient-centered approach and the longitudinal nature of the interventions which length depends on the type of ICS. The corresponding ICS template is used as a library of resources for the correct customization and execution of the ICS workflow. Integration with corporate Electronic Health Record (EHR) allows instant access to required patient information for case identification and evaluation, avoid data duplicity and preserve the current corporate clinical data chain of custody. Follow-up and discharge reports can also be sent to the corporate EHR to keep trace of the ICS execution as part of the patient clinical episodes.

Mentions: One of the Synergy-COPD goals was to facilitate elaboration of refined subject-specific health risk assessment with a holistic patient-oriented approach. Such modeling approach constitutes the basis for 4P medicine facilitating the design of early interventions with a preventive orientation. Moreover, the prediction of health risk should contribute to patient-based stratification in the healthcare arena, as indicated in Figure 2 wherein the logical sequence for chronic care management is displayed [20,21].


Synergy-COPD: a systems approach for understanding and managing chronic diseases.

Gomez-Cabrero D, Lluch-Ariet M, Tegnér J, Cascante M, Miralles F, Roca J, Synergy-COPD consorti - J Transl Med (2014)

Workflow for an Integrated Care Service (ICS) management and execution. The patient is allocated into an ICS defined as a set of well standardized tasks to be carried out on the basis of his/her health condition and social circumstances to achieve target objectives aligned with the comprehensive treatment plan. Two differential ICS characteristics, as compared to usual care, are the patient-centered approach and the longitudinal nature of the interventions which length depends on the type of ICS. The corresponding ICS template is used as a library of resources for the correct customization and execution of the ICS workflow. Integration with corporate Electronic Health Record (EHR) allows instant access to required patient information for case identification and evaluation, avoid data duplicity and preserve the current corporate clinical data chain of custody. Follow-up and discharge reports can also be sent to the corporate EHR to keep trace of the ICS execution as part of the patient clinical episodes.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4255903&req=5

Figure 2: Workflow for an Integrated Care Service (ICS) management and execution. The patient is allocated into an ICS defined as a set of well standardized tasks to be carried out on the basis of his/her health condition and social circumstances to achieve target objectives aligned with the comprehensive treatment plan. Two differential ICS characteristics, as compared to usual care, are the patient-centered approach and the longitudinal nature of the interventions which length depends on the type of ICS. The corresponding ICS template is used as a library of resources for the correct customization and execution of the ICS workflow. Integration with corporate Electronic Health Record (EHR) allows instant access to required patient information for case identification and evaluation, avoid data duplicity and preserve the current corporate clinical data chain of custody. Follow-up and discharge reports can also be sent to the corporate EHR to keep trace of the ICS execution as part of the patient clinical episodes.
Mentions: One of the Synergy-COPD goals was to facilitate elaboration of refined subject-specific health risk assessment with a holistic patient-oriented approach. Such modeling approach constitutes the basis for 4P medicine facilitating the design of early interventions with a preventive orientation. Moreover, the prediction of health risk should contribute to patient-based stratification in the healthcare arena, as indicated in Figure 2 wherein the logical sequence for chronic care management is displayed [20,21].

Bottom Line: The challenges posed by the epidemics of CD have triggered a novel health paradigm with major consequences on the traditional concept of disease and with a profound impact on key aspects of healthcare systems.The current manuscript describes main features of the project design and the strategies put in place for its development, as well the expected outcomes during the project life-span.Moreover, the manuscript serves as introductory and unifying chapter of the different papers associated to the Supplement describing the characteristics, tools and the objectives of Synergy-COPD.

View Article: PubMed Central - HTML - PubMed

ABSTRACT
Chronic diseases (CD) are generating a dramatic societal burden worldwide that is expected to persist over the next decades. The challenges posed by the epidemics of CD have triggered a novel health paradigm with major consequences on the traditional concept of disease and with a profound impact on key aspects of healthcare systems. We hypothesized that the development of a systems approach to understand CD together with the generation of an ecosystem to transfer the acquired knowledge into the novel healthcare scenario may contribute to a cost-effective enhancement of health outcomes. To this end, we designed the Synergy-COPD project wherein the heterogeneity of chronic obstructive pulmonary disease (COPD) was addressed as a use case representative of CD. The current manuscript describes main features of the project design and the strategies put in place for its development, as well the expected outcomes during the project life-span. Moreover, the manuscript serves as introductory and unifying chapter of the different papers associated to the Supplement describing the characteristics, tools and the objectives of Synergy-COPD.

Show MeSH
Related in: MedlinePlus