How to reduce the need for in-person visits to healthcare centers while increase self disease management?
The challenges
A leading healthcare provider sought to minimize unnecessary in-person visits while maintaining high-quality patient care. Their goal was to create a seamless, end-to-end digital ecosystem that supports patients across all stages of chronic care—before, during, and after treatment. Key challenges included:
Managing administrative burdens for chronic and post-surgical patients.
Ensuring proactive monitoring to prevent complications and reduce hospital readmissions.
Enabling personalized, real-time communication between patients and clinicians.
Automating workflows to optimize resource allocation and reduce costs.
The Solution
We developed an integrated health monitoring platform designed to empower patients and streamline clinician workflows.
The context
Managing chronic conditions like diabetes, hypertension, and heart disease requires continuous, personalized care. However, traditional models often fail to:
Detect early warning signs of deterioration due to infrequent in-person check-ups.
Ensure consistent patient adherence to treatment plans.
Provide real-time communication between patients and care teams.
The research
This project employed a mixed-methods, human-centered approach to design a digital ecosystem aimed at improving chronic care management while reducing administrative burdens and unnecessary in-person visits. The research design included:
Contextual Inquiry & Field Observation
Direct observation of 10 clinical consultations (e.g., rheumatology) to identify friction points in patient record-keeping and follow-up practices.
On-site workflow analysis across specialties (reumatology, endocrinology, obstetrics) to map information needs and care coordination challenges.
Co-Creation & Collaborative Design
Participatory workshops with clinical teams to co-design solutions, focusing on standardizing minimum workflows and integrating tools like status tracking (e.g., "pending/complete" registries) to simplify processes.
Emphasis on interdisciplinary alignment to balance specialty-specific needs with system-wide efficiency (e.g., diabetes, hypertension, post-surgical care).
Patient-Centered Validation
Prototype testing with patients to validate usability and relevance, ensuring solutions addressed gaps in adherence, communication, and real-time monitoring.
Testimonials and feedback loops to refine features like automated alerts and personalized care plans.
Process Optimization Goals
Identified opportunities to automate workflows (e.g., reducing manual data entry, optimizing resource allocation) and enable proactive monitoring to prevent complications.
Explored solutions for real-time communication to bridge gaps between infrequent check-ups and continuous care needs.
Patient portal key features to empower self-managment
Main Health Metric Tracking: Patients log critical health parameters (e.g., blood glucose, blood pressure, SpO2) via a unified home dashboard. The system highlights their main metric parameter (e.g., HbA1c for diabetes), ensuring focus on the most vital indicator.
Automated Reminders: Automated nudges via WhatsApp or email prompt patients to submit readings, complete surveys, or take medications based on medical's protocol.
Educational Hub: Curated articles and videos explain condition-specific self-care strategies, fostering patient empowerment.
Bidirectional Messaging: Patients securely communicate symptoms or concerns to their care team, receiving personalized feedback within hours.
Clinician dashborad key features for proactive care
Real-Time Trend Analysis: Dynamic graphs and heatmaps display patient-reported data, flagging deviations from safe thresholds (e.g., systolic BP > 140 mmHg).
Risk Stratification: Patients are categorized by urgency (green/yellow/red) based on their gold standard trends, enabling prioritization of high-risk cases.
Customizable Protocols: Clinicians adjust monitoring frequency, survey types (e.g., PHQ9 for depression screening), and alert rules to match individual needs.
Medication Management: Track adherence, renew prescriptions, and send dosage adjustments directly through the portal.
Key Features increasing adherence
Threshold-Based Alerts: Clinicians receive instant SMS/email notifications if critical values (e.g., hypoglycemia) are detected.
Longitudinal Data Visualization: Compare historical trends to identify deterioration patterns.
Predefined & Custom Surveys: Mix standardized assessments (e.g., GAD7 for anxiety) with condition-specific questions.
Multi-Device Access: Patients submit data via web, mobile app, or WhatsApp—no tech expertise required.
Patient adherence
89%
improve
Adherence rate daily/weekly metric submissions, up from 52% pre-implementation.
Digital tracking
100%
digital
Zero paper-dependent workflows post-implementation, with all data captured, stored, and analyzed digitally (in the gestiational diabetes program)