While traditionally, health-care services have been focused on sick-care management, we need to review some of the current service delivery models to manage patients with longer-term or chronic diseases more effectively, taking a more patient-centred approach. We need more horizontal integration within and across disciplines and a new model for managing chronic diseases, moving from many concurrent specialties to a matrix of services that offers greater flexibility in addressing patients’ changing needs.
Integrated and cross-specialty care is going to be the watchword of the future in chronic disease management. This involves greater collaboration across specialties, collaboration with the social sector at the community level, more health education programmes for patients and carers, and extensive use of information technology.
One good example is the
Risk Factor Assessment and Management Programme for enhancing chronic disease management. Patients with
diabetes and
hypertension at our primary-care clinics are systematically assessed and cared for by multidisciplinary teams of nurses and allied health professionals. This enables the risk of complications to be stratified, so we can provide targeted clinical interventions and empower them to care for themselves.
It is very clear that IT is playing an increasingly important role in managing the treatment pathways of chronic diseases. The advent of “
big data” and rapid advances in artificial intelligence will enable our future IT services to go far beyond today’s functions and capability. Besides facilitating real-time assessment and early intervention, they
can be predictive and play a much bigger role in the prevention and care of chronic diseases.
Our vision is to see the vast majority of older patients age happily in their home environment,
monitoring their own health as far as possible and keeping medical appointments or hospital stays to a minimum. This will require us all to take a wider perspective and develop a new model of patient-centred care.
Dr P. Y. Leung, chief executive, Hospital Authority
This article appeared in the South China Morning Post print edition as: Big data can enhance health care for our ageing population and chronic-disease patients
