Intelligent Internet-based information system optimises diabetes mellitus management in communities

Abstract

Objective:

To evaluate the effect of an intelligent Internet-based information system upon optimising the management of patients diagnosed with type 2 diabetes mellitus (T2DM).

Methods:

In 2015, a T2DM information system was introduced to optimise the management of T2DM patients for 1 year in Fangzhuang community of Beijing, China. A total of 602 T2DM patients who were registered in the health service centre of Fangzhuang community were enrolled based on an isometric sampling technique. The data from 587 patients were used in the final analysis. The intervention effect was subsequently assessed by statistically comparing multiple parameters, such as the prevalence of glycaemic control, standard health management and annual outpatient consultation visits per person, before and after the implementation of the T2DM information system.

Results:

In 2015, a total of 1668 T2DM patients were newly registered in Fangzhuang community. The glycaemic control rate was calculated as 37.65% in 2014 and significantly elevated up to 62.35% in 2015 (p < 0.001). After application of the Internet-based information system, the rate of standard health management was increased from 48.04% to 85.01% (p < 0.001). Among all registered T2DM patients, the annual outpatient consultation visits per person in Fangzhuang community was 24.88% in 2014, considerably decreased to 22.84% in 2015 (p < 0.001) and declined from 14.59% to 13.66% in general hospitals (p < 0.05).

Conclusion:

Application of the T2DM information system optimised the management of T2DM patients in Fangzhuang community and decreased the outpatient numbers in both community and general hospitals, which played a positive role in assisting T2DM patients and their healthcare providers to better manage this chronic illness.

Keywords

information systems diabetes mellitus type 2 disease management patient education self-care health information management China

Introduction

As the most populous country in the world, China has undergone significant demographic, societal and economic transformations. In 2011, the State Council of China promulgated the establishment of a decentralised healthcare system across the nation. Ongoing changes have promoted the evolution and flourishing of community-based healthcare services. As the baseline of a decentralised medical system, a degree of progress has been achieved in the management of several chronic diseases, especially type 2 diabetes mellitus (T2DM). Due to the large population of T2DM patients and limited medical resources in the community, electronic health records (EHRs) have not been established in a majority of primary level medical institutions (Cotter et al., 2014), and multiple challenges still exist in the application of EHRs for the registered residents within a community: lack of instant update of EHRs, difficulty in sharing resident EHRs among different levels of hospitals, passive mode of disease management, inconsistent implementation and low degree of participation by community residents (Gooch and Roudsari, 2011; Schrader et al., 2014; Toma et al., 2014). The limited application of electronic information systems has severely affected the implementation of community-based prevention and management of chronic diseases. To resolve this challenge, information technology was trialled for the management of T2DM patients in the health service centre of Fangzhuang community in Beijing. A resident demand-oriented intelligent Internet-based information system was established and applied to optimise the efficacy and quality of management of T2DM patients, aiming to provide a basis for establishing a decentralised medical system throughout China. The aim of this study was to evaluate the effect of an intelligent Internet-based information system in optimising the management of T2DM patients.

Methods

Ethics and consent statement

This study was approved by the ethics committee of Fangzhuang Community Health Service Center in Fengtai District, Beijing, China, on May 2014. Participants have provided their written informed consents to participate in this study.

Study design

Before and after the implementation of the T2DM information system, multiple parameters including glucose level, haemoglobin A1c (GHbA1c) level, incidence of concomitant diseases, body mass index (BMI) and blood pressure were quantitatively measured and statistically compared. The information system performed data analysis and generated a chart illustrating the dynamic change and tendency using varying functions, such as real-time warning, dynamic tracking, data loading and comprehensive analysis, dynamic data description, bidirectional referral and performance assessment.

Study subjects

Sampling methods

Using the isometric sampling method, a total of 602 T2DM patients registered in our community were enrolled. During subsequent follow-up, two patients died, two were lost to follow-up and eight relocated to other cities and rejected the follow-up. Eventually, 587 T2DM patients were eligible for subsequent analysis.

Inclusion criteria

Patients were diagnosed with T2DM according to the World Health Organization diagnostic criteria for diabetes mellitus (1999). All patients came from Fangzhuang community and written informed consent was collected from each participant. The patients were aged between 30 and 84 years old, had been covered by a medical insurance scheme in urban Beijing for at least 2 years and did not participate in other ongoing public health interventions at the same time.

Exclusion criteria

Patients with one or more of the following conditions were excluded: serious T2DM-related complications; severe heart, liver and renal dysfunction; severe neurological or psychiatric disorders; alcohol or drug abuse; pregnant or breast feeding women; difficulty in communication.

Establishment and application of the T2DM information system

Prior to the establishment of the new information system, a literature search, peer exchange, panel discussion and specialist consultation were conducted to determine the structure and design of the system. The staff from Yuxin Network Future, Beijing, China, medical staff from the community, physicians from Beijing Tiantan Hospital and technicians from Beijing Public Health Information Center attended the meeting to integrate and update the original system and connect the new system to the Beijing Community-Based Public Service System. Technical supports were delivered to make different system modules compatible and establish an intelligent Internet-based information system in the Fangzhuang community. On the basis of the original system, new modules and functions were supplemented to share the EHRs of all patients among the health service centre, tertiary referral hospital and public health system.

Application of T2DM information system

This T2DM information system consisted of multiple functions including real-time warnings, dynamic tracking, data loading and comprehensive analysis, dynamic data description, bidirectional referral and performance assessment. These functions assisted patients to ensure that issues related to the management of their T2DM could be resolved appropriately and in a timely fashion. The modules of the T2DM information system of T2DM patients in Fangzhuang community are illustrated in Figure 1.

Figure 1.

Modules of T2DM information system. T2DM: type 2 diabetes mellitus.

Real-time warning

By means of this information system, the recent physical condition of the patients was recorded and searchable. The present blood glucose level and concomitant diseases could be displayed automatically. Based upon the severity of the disease, the patients’ records are labelled by one of three coloured icons (red, yellow and blue), as the real-time warning signs. A red icon indicated that the health problem should be closely monitored and preferentially resolved within 3 days by the family physician; a yellow icon indicated the health problem should be addressed within 7 days; while a blue icon denoted the health problem should be treated within 2 weeks, as outlined in Table 1 in details.

Table 1.

Illustration of the red, yellow and blue icons of the information system.

Warning icons	Health problem
Red icon	Blood glucose level at random < 3.9 mmol/L, FPG > 13.9 mmol/L and/or PPG > 16.7 mmol/L; GHbA1c > 12%; blood pressure < 90/60 mmHg or >180/110 mmHg; TG level > 5.65 mmol/L; atherosclerotic stenosis ≥ 75%; complicated with acute coronary artery syndrome; acute ischemic stroke; UACR ≥ 300 mg/24 h, stages IV and V of CKD; proliferative diabetic retinopathy; stage IV of LEAD; others
Yellow icon	FPG > 7 mmol/L and/or PPG > 11.1 mmol/L; GHbA1c: 10–12%; blood pressure: 160–180/100–110 mmHg; TC level > 6.22 mmol/L, LDL-C ≥ 4.14 mmol/L, and/or TG: 2.26–5.64 mmol/L, with no medication therapy; atherosclerotic stenosis < 75%; complicated with unstable angina; UACR ≥ 30 mg/24 h, stages II and III of CKD; severe NPDR; stage IIb and III of LEAD.
Blue icon	FPG: 6.1–7.0 mmol/L and/or PPG > 11.1 mmol/L; GHbA1c: 7–10%; blood pressure in patients aged < 65 years: 140–160/80–100 mmHg and 150–160/90–100 mmHg for those aged > 65 years; TC: 5.18–6.19 mmol/L, LDL-C: 3.37–4.12 mmol/L, and/or TG: 1.70–2.25 mmol/L, with no medication use; complicated with arterial atherosclerotic plaque with no medication therapy; UACR ≥ 30 mg/24 h, stage I of CKD; slight and moderate NPDR; stage IIa of LEAD.

FPG: fasting plasma glucose; PPG: postprandial glucose; GHbA1c: haemoglobin A1c; TG: triglyceride; UACR: urinary albumin/creatinine ratio; CKD: chronic kidney disease; PDR: proliferative diabetic retinopathy; LEAD: lower extremity atherosclerotic disease; LDL-C: low-density lipoprotein cholesterol; NPDR: non-proliferative diabetic retinopathy.

Dynamic tracking

The management criteria of T2DM were based upon the National Basic Public Health Service Standards in 2013. The patients are listed in the information system according to the recent follow-up date. The management and follow-up record of the patients are displayed forefront. Patients failing to attend the follow-up as scheduled are automatically highlighted in red font. The community physicians are responsible for checking the follow-up progress in the information system, communicating with the patients by telephone and/or texting to deliver disease management information and arrange the date of a return visit.

Data load and comprehensive analysis

At the time of quarterly follow-up and yearly evaluation, the laboratory data, imaging data and health self-test outcomes were automatically loaded into the EHRs. These test results combined with the examination outcomes in other hospitals were then compiled to generate the health assessment report, including target of individual treatment, risk of cardiovascular events, non-medication and/or medication therapy, healthcare education and guidance and follow-up planning, such as the examination, date and frequency of follow-up. According to the health assessment report, the family physician determined individual health management plans and/or arranged the date of return visit.

Dynamic data description

Community physicians obtained the clinical data from physical examination and other examinations such as blood glucose level, BMI and blood pressure. The information system then performed the data analysis and generated a chart illustrating the dynamic change and tendency. According to Table 1, community physicians delivered overall assessments on the effectiveness of management of T2DM patients and made corresponding adjustments.

Bidirectional referral between Fangzhuang community and Tiantan Hospital

For patients who required further treatment, a bidirectional referral request from Fangzhuang community and Tiantan Hospital could be proposed and implemented through the information system. Upon receiving the referral request, physicians in the Tiantan Hospital could directly read the EHRs and test results of the patients within their hospital information system (HIS) and arrange outpatient treatment, relevant examinations and hospitalisation as indicated. Following diagnosis and treatment, the physicians from Tiantan Hospital uploaded the health record, imaging data, risk assessment of the health problem and treatment plan to the EHRs, which was accessible by the family physicians from Fangzhuang community.

Short message service

By connecting to the platform of Beijing Public Health Information Centre, this information system delivered the EHRs, return visit appointment, referral appointment, health education courses and health knowledge to the registered cellular phone numbers of patients and their family members via short message service (SMS) function.

Information inquiry

A website of the Health Service Center of Fangzhuang community was established to provide information inquiry services for registered residents. Residents could log into their accounts by providing registered phone numbers or personal identification (ID), input the identifying code sent to their phones and then check the EHRs of their own and family members.

Performance assessment

Performance assessment parameters, including the number of T2DM patients, integrity of registered patient EHRs, update status, percentage of patients receiving standard management, time of problem resolving and the glycaemic control rate, could be searched, evaluated and compared among different teams within the information system.

Data collection

Through the data monitor module of the information system, data inquiry and statistical analysis were performed to evaluate the rate of standard health management of T2DM patients. Complying with the regulations of National Basic Public Health Service Standards (2013 version), the standard health management for T2DM patients included at least four follow-up sessions each year in the form of outpatient attendance, telephone discussion and home visits, one health evaluation each year and one comprehensive physical examination each year. The equation of standard health management rate for T2DM patients was calculated as the number of T2DM patients receiving standard health management/the total number of T2DM patient × 100%.

GHbA1c detection and glycaemic control rate

GHbA1c detection was performed using immunochromatography (Rapid test GHbA1c analyzer; Wondfo Biotech, Guangzhou, China). Glycaemic control, referred to GHbA1c level, was maintained below 7% for T2DM patients aged < 65 years and 8% for those aged 65 years and over. No severe hypoglycaemia-related events occurred. The glycaemic control rate was defined as the percentage of T2DM patients with controlled GHbA1c for over 6 months within a year to the total number of T2DM patients receiving specific health management. The glycaemic control rate equation = the number of T2DM patients with glycaemic control/the total number of T2DM patients receiving specific health management.

Annual outpatient consultation visits per person

Clinical data were extracted from Beijing Administrative Center for Medical Insurance Affairs. The diagnosis of T2DM was confirmed by the initial outpatient consultation. The annual outpatient consultation visits per person and length of hospital stay were equally compiled to establish a database.

Statistical analysis

SPSS 17.0 statistical software was used for data analysis. Measurement data were expressed as mean ± standard deviation. The difference in the mean values before and after 2-year intervention was statistically compared by the two-sample t-test. Enumeration data were described in percentage and statistically compared by using χ² test. A value of p < 0.05 was considered statistically significant. The data satisfied the assumption of normality when assessed by the Shapiro–Wilk test.

Results

Baseline data

In this study, a total of 587 T2DM patients who were registered in Fangzhuang community of Beijing were recruited for the study. Patients were aged between 30 and 91 years, (61.6 ± 7.3) years on average. Among them, 234 (39.9%) were males and 353 females (60.1%).

Evaluation of T2DM management effect

According to the data extracted from Beijing Administrative Center for Medical Insurance Affairs, the glycaemic control rate was calculated as 37.65% in 2014, significantly elevated up to 62.35% in 2015 (p < 0.001). In 2014, the rate of standard health management was 48.04%, significantly enhanced to 85.01% in 2015 (p < 0.001). In addition, the proportion of telephone follow-up was equally increased from 13.94% in 2014 to 32.64% in 2015 (p < 0.001), as illustrated in Table 2.

Table 2.

Comparison of management effect and T2DM-related parameters before and after intervention (n = 587).

Year	2014	2015
Glycaemic control rate, n (%)	221 (37.65)	366 (62.35)^a
The percentage of T2DM patients receiving standard health management, n (%)	282 (48.04)	499 (85.01)^a
Telephone follow-up, n (%)	818 (13.94)	1916 (32.64)^a
Home visit (n)	46	36
Annual outpatient consultation visits per person in community health centre	24.88 ± 13.11	22.84 ± 13.13^a
Annual outpatient consultation visits per person in general hospital	14.59 ± 13.22	13.66 ± 12.20
Yearly frequency of hospitalisation in general hospital	0.22 ± 0.69	0.23 ± 0.81
Number of hospitalised T2DM patients in general hospital (n)	131	133
Bidirectional referral (n)	2	21

T2DM: type 2 diabetes mellitus.

^aStatistical significance compared with the data measured in 2014.

Compared with the registered population, 1668 T2DM patients were newly registered in Fangzhuang community, adding the total quantity of T2DM registers to 5640 cases and the registration rate of T2DM patients in Fangzhuang community achieved up to 65.06%.

Annual outpatient consultation visits and referral per person

In 2014, the average annual outpatient consultation visits per person to the community health centre for each T2DM patient registered in Fangzhuang community was 24.88 times yearly, significantly declining to 22.84 times in 2015 (p < 0.001). Moreover, the mean annual outpatient consultation visits per person to the general hospital was 14.59 times in 2014, decreasing significantly to 13.66 times in 2015 (p < 0.05). However, the average frequency of hospital stay in general hospitals did not significantly differ between 2014 and 2015 (p > 0.05). Additionally, merely two cases were referred to general hospitals in 2014 and 21 patients in 2015.

Discussion

Diabetes mellitus is a chronic disease that constitutes a major public health problem. The worldwide prevalence of diabetes mellitus has risen tremendously over the past two decades (Garcia et al., 2013; Gascón et al., 2013; Liaw et al., 2014; Wicks et al., 2014). It has been predicted that the population of individuals with diabetes mellitus will continue to increase in the near future. The proper control of the illness is dependent on the patient’s adherence to medications, lifestyle modifications and frequent monitoring of blood glucose (Chan et al., 2014; Pal et al., 2014; Ramadas et al., 2011; Wells et al., 2015). In this article, an Internet-based comprehensive information system to assist with the management of T2DM (T2DM information system) was trialled with T2DM patients who were registered in Fangzhuang community from Beijing, China. This novel information system integrated multiple vital functions. First, it was capable of optimising the work flow for T2DM patients. Second, it established seamless communication between the community healthcare workers and diabetic patients using cellular phones or through a website to form online communities for information sharing, support and collaboration. Through the information system, a smooth channel was constructed between the community health centre and the general hospital (Tiantan Hospital) to establish a long-term partnership for medical service suppliers of different levels.

After 1-year of the intervention, the glycaemic control rate in T2DM patients was significantly enhanced, which is consistent with previous findings (Solomon et al., 2012). As active participation by and personal responsibility of the patients are required during diabetes mellitus management, the paradigm of T2DM self-management interventions has shifted to an approach that focuses upon patient-centred behavioural change techniques to deliver training in problem solving, self-efficacy enhancement, attitudes on behavioural alteration and information-oriented education (Solomon et al., 2012). According to the automatically generated comprehensive assessment report and dynamic tendency graph of health indicators, family physicians can systematically assess the management effect upon glycaemic control and management behaviour. Thus, they are able to deliver immediate and tailored strategies for those diabetic patients registered in our community. Under certain circumstances, community medical services can fail to manage and resolve acute severe symptoms. In such cases, these diabetic patients should be referred to a high-level general hospital. Subsequently, a bidirectional communication mechanism was successfully established between Fangzhuang community and Tiantan Hospital, a general hospital in Beijing. Through this information system in the community connecting to the HIS system in the general hospital, the community healthcare workers and medical staff in Tiantan Hospital could coordinate the diagnosis, treatment and management of patients with diabetes. These efforts were made to enhance the service quality and efficacy for the T2DM patients registered in Fangzhuang community.

In addition, after this information system intervention, the percentage of patients with diabetes receiving standard health management was significantly elevated, which is consistent with previous investigations (Dobson et al., 2016; Solomon et al., 2012). These advantages ascribe to the following functions. In the information system, patients who are lost to follow-up or fail to attend the follow-up will be automatically highlighted. Subsequently, the community healthcare workers will actively contact and remind these patients of immediate follow-up. This specific function allows the community physicians to avert the incidence of follow-up loss and guarantees continuous health management for T2DM patients. Using the data load function, the examination data of the patients were directly synchronised into the EHR, which properly avoided the incidence of typographical errors and enhanced the efficiency of T2DM patient management.

In this investigation, the use of this information system significantly decreased the annual outpatient consultation visits per person in the community health centre and general hospitals. In the Fangzhuang community (the pilot site), the community medical staff fully utilised the information-aided technology to deliver dynamic monitoring and private management for each T2DM patient registered in this community. Meantime, community intervention on improving knowledge and glycaemic control showed better progress in the recovery of T2DM. Continuous counselling and monitoring played a pivotal role in glycaemic control. Intervention by community medical staff exerted a beneficial effect on the clinical management of T2DM. Assessing the knowledge and practice of community physicians can help to design appropriate targeted educational training for diabetic patients’ benefit. In addition, the awareness and cooperation of the patients and their family members also helped determine the success of T2DM management (Arambepola et al., 2016; Dobson et al., 2016; Hogan et al., 2011; Nihat et al., 2016).

Study limitations

The lack of a control group meant this study was unable to account for any other potential background changes that may have impacted the outcomes. Further studies, including control groups, larger sample sizes and follow-up over longer time frames, are needed. In the current study, all enrolled patients were covered by Beijing Urban Basic Medical Insurance. In future, other residents should be recruited and included. More importantly, this information system should be applied across a wider group of communities to broaden its application range and optimise the management effect.

In this present study, we applied univariate analysis for evaluation and did not take into account the effects of other factors, since we believed the adoption of the system would play the key role in making the differences between the two groups. In our future work, we will continue our evaluation and apply multivariate analysis to explore the potential impact of different variables.

Conclusions

The SMS and Internet-based information inquiry functions provided effective guidance in the understanding of the risk factors of T2DM, enhanced understanding of scientific management and simultaneously utilised the limited medical resources to full potential. Moreover, the performance assessment module used in this information system also enhanced the effect and efficiency of the management of the administrative staff in the Fangzhuang community. The quantity and quality of clinical management provided by each community physician can be explicitly recorded and displayed, which provides a consolidated basis for annual performance evaluation for community medical staff. This function not only allows for equal assessment of work performance but can also inspire the passion and motivation of community physicians to supply high-quality medical service for T2DM patients.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by grants from The Capital Health Development Research and Special Projects (Funding No. 2014-2-7051).

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