IN THE FIELD OF TECHNOLOGY DEGREE PROJECT
INDUSTRIAL ENGINEERING AND MANAGEMENT AND THE MAIN FIELD OF STUDY
INDUSTRIAL MANAGEMENT, SECOND CYCLE, 30 CREDITS STOCKHOLM SWEDEN 2019,
Managing Chronic Conditions
Through Digital and Patient-centric Care
A study on asthma patient preferences for a digital health care service
CLARA CALMERED JOSEFIN KULLMAN
KTH ROYAL INSTITUTE OF TECHNOLOGY
Managing Chronic Conditions Through Digital and Patient-centric Care
A study on asthma patient preferences for a digital health care service
by
Clara Calmered Josefin Kullman
Master of Science Thesis TRITA-ITM-EX 2019:278 KTH Industrial Engineering and Management
Industrial Management
SE-100 44 STOCKHOLM
Kroniska tillstånd i en digital och patientcentrerad vårdtjänst
En studie om astmapatienters preferenser i användandet av en digital hälsovårdstjänst
av
Clara Calmered Josefin Kullman
Examensarbete TRITA-ITM-EX 2019:278 KTH Industriell teknik och management
Industriell ekonomi och organisation
SE-100 44 STOCKHOLM
Master of Science Thesis TRITA-ITM-EX 2019:278
Managing Chronic Conditions Through Digital and Patient-centric Care
Calmered, Clara Kullman, Josefin
Approved
2019-05-29
Examiner
Brown, Terrence
Supervisor
Blomgren, Henrik
Commissioner
Doktor24
Contact person
Lillienau, Daniel
Abstract
Chronic diseases account for about 80\% of the total health care costs in Sweden, where the current health care system is designed according to the characteristics of acute diseases. Chronic care management is characterized by a long-term perspective and inclusion of multiple health care practitioners during the care process. New and more advanced digital health care solutions have emerged due to technology progress followed by increased use of consumer electronics. It creates opportunities to customize and advance health care services. Existing digital health care offerings include functions designed for acute symptoms, and single digital consultation sessions and treatments plans extending over a shorter period of time. There is a significant shortcoming of existing digital health care services for chronic patients, and research is lacking on how to construct such a service.
The research was conducted with the digital health care provider Doktor24. The data for the study was both quantitatively and qualitatively collected through collection of existing statistical data and a patient survey, and interviews with patients and medical care personnel.
Identified requirements indicate that asthma patients are not satisfied with the current physical asthma care process, where the process today is time-consuming and not particularly adjusted to benefit asthmatics. Patient preferences were summarized in three major aspects; accessibility and time efficiency, a dynamic customized treatment plan and independent self care. Determined functions were digital visits, digital spirometry, notifications and education and information. Together the functions form the basis for a digital chronic care solution for asthma patients.
The thesis contributes to research by presenting a unique exploration on the existing opportunities with a patient-centric digital health care service for asthma patients.
Key-words: Digital health care, digital service, chronic care, asthma care, digital asthma care TRITA-ITM-EX 2019:278
Examensarbete TRITA-ITM-EX 2019:278
Kroniska tillstånd i en digital och patientcentrerad vårdtjänst
Calmered, Clara Kullman, Josefin
Godkänt
2019-05-29
Examinator
Brown, Terrence
Handledare
Blomgren, Henrik
Uppdragsgivare
Doktor24
Kontaktperson
Lillienau, Daniel
Sammanfattning
Kroniska sjukdomar motsvarar idag ungefär 80% av totala sjukvårdskostnaderna i Sverige, där det nuvarande sjukvårdssystemet är utformat utifrån akuta sjukdomar. Kronisk vårdhantering karakteriseras av ett långsiktigt perspektiv, samt av flertalet involverade vårdaktörer. Nya och mer avancerade digitala sjukvårdslösningar har uppstått som ett resultat av teknologiska framsteg samt ett ökat användande av digitala hjälpmedel. Det skapar möjligheter att skräddarsy och utveckla sjukvårdstjänster. Existerande digitala erbjudanden inkluderar funktioner och lösningar för akuta symtom och sjukdomar, och enstaka digitala konsultationer samt behandlingsplaner som sträcker sig över en kortare tidsperiod. Det finns idag en tydlig brist i utbudet av digitala sjukvårdstjänster för kroniskt sjuka.
Studien utfördes i samarbete med den digitala sjukvårdsaktören Doktor24. Datainsamlingen inkluderade både kvantitativ och kvalitativ data, bestående av existerande statistik och en patientundersökning, samt utförda intervjuer med patienter och vårdpersonal.
Identifierade krav indikerar att astmapatienter inte är nöjda med den existerande fysiska sjukvårdsprocessen, då processen idag är tidskrävande och inte speciellt anpassad för astmatiker. Patientpreferenserna sammanfattades i tre aspekter; tillgänglighet och tidseffektivitet, en dynamiskt anpassad behandlingsplan samt utbildning och information. Tillsammans utgör funktionerna grunden för en digital kronisk sjukvårdstjänst för astmatiker.
Studien bidrar till forskning genom att presentera en unik undersökning av existerande möjligheter med en patient-centrerad digital sjukvårdstjänst för astmatiker.
Nyckelord: Digital sjukvårdstjänst, digital sjukvård, kronisk sjukvård, astma, digital astma
Contents
1 Introduction 1
1.1 Background . . . 1
1.2 Problem Formulation . . . 1
1.3 Purpose and Aim . . . 2
1.4 Research Questions . . . 2
1.5 Delimitation . . . 2
1.6 Contribution to Science . . . 3
1.7 Disposition . . . 3
2 Pre-Study 5 2.1 Background Setting . . . 5
2.1.1 Doktor24 . . . 5
2.2 Chronic Diseases in Sweden . . . 5
2.2.1 Asthma . . . 7
3 Literature Review 9 3.1 Value Based Health Care . . . 9
3.1.1 Organize health care based on patient’s medical condition . . . 10
3.1.2 Measure outcomes and patient costs . . . 11
3.1.3 Bundled payments for full care cycle . . . 12
3.1.4 Integrate care delivery system . . . 13
3.1.5 Geographic expansion . . . 14
3.1.6 Information technology platform . . . 14
3.2 Digital Health Care . . . 14
3.2.1 Synchronous and Asynchronous Communication . . . 16
3.2.2 Digital Asthma Solutions . . . 17
3.2.3 Data Protection Security . . . 18
3.3 Self Management . . . 19
3.4 Synthesis of Literature . . . 21
4 Method 23 4.1 Research Approach . . . 23
4.2 Research Design . . . 23
4.3 Research Process . . . 23
4.3.1 Pre-Study . . . 24
4.3.2 Data Collection . . . 24
4.3.3 Literature Review . . . 26
4.3.4 Analysis and Discussion . . . 27
4.4 Quality of Research Design . . . 27
4.4.1 Reliability and Validity . . . 27
4.4.2 Ethic Research . . . 27
5 Results 28 5.1 Asthma Patient Survey . . . 28
5.1.1 Physical Asthma Care . . . 28
5.1.2 Digital Asthma Care . . . 30
5.2 Asthma Patient Interviews . . . 32
5.2.1 Physical Asthma Care . . . 32
5.2.2 Digital Asthma Care . . . 33
5.2.3 Other . . . 34
5.3 Asthma Care Personnel Interviews . . . 35
5.3.1 Physical Asthma Care . . . 35
5.3.2 Digital Asthma Care . . . 37
5.3.3 Other . . . 38
5.4 Landstinget . . . 38
5.4.1 Capitation Model . . . 38
6 Analysis and Discussion 41 6.1 Physical Asthma Care . . . 41
6.1.1 Patient Purpose of Medical Visits . . . 41
6.1.2 Improvement Areas . . . 43
6.2 Digital Asthma Care . . . 44
6.2.1 Opportunities of a digital value based asthma care service . . . 44
6.2.2 Resources . . . 47
7 Conclusions 51 7.1 RQ1 . . . 51
7.2 RQ2 . . . 51
7.3 RQ3 . . . 51
7.4 Main RQ . . . 52
7.5 Contribution to Academia and Industry . . . 53
7.6 Sustainability Aspects . . . 53
7.7 Limitations . . . 53
References 55 A Appendices 59 A.1 Asthma Patient Survey . . . 59
A.2 Interview Guide for the Asthma Patients . . . 63
A.3 Interview Guide for the Asthma Care Personnel . . . 64
List of Figures
1 Population in Sweden living with one chronic disease (SCB, 2013) . . . 6
2 Summary of the most common chronic diseases in relation to the Swedish pop- ulation . . . 6
3 Summary of chronic diseases in relation to the Swedish population, and with respect to age . . . 7
4 Impact on health status with respect to regions (Socialstyrelsen, 2017) . . . 8
5 Value through coordination (Tierney, 2018) . . . 9
6 Virtuous circle of value creation (Porter and Lee, 2013) . . . 11
7 The outcome measures hierarchy (Porter and Lee, 2013) . . . 12
8 Payment system (Miller, 2009) . . . 13
9 Illustration of self management (Lee et al., 2011) . . . 21
10 Theoretical framework . . . 22
11 Illustration of the research process . . . 24
12 Age group distribution . . . 28
13 Type of asthma - Multiple choice question . . . 28
14 Medical care frequency . . . 29
15 Spirometry frequency . . . 29
16 Asthma impact on health status . . . 30
17 Frequency for not seeking care . . . 30
18 Interest in using a digital health care service for asthma . . . 31
19 Why digital health care service for asthma . . . 31
20 Purpose of medical care visits . . . 31
21 Additional services besides regular asthma health care . . . 32
22 Importance of personal contact . . . 32
23 Quick reply vs personal contact . . . 32
24 Flowchart of research questions . . . 41
25 Illustration of the current asthma care process in Sweden . . . 43
26 Illustration of the asthma care process as proposed by Socialstyrelsen (2015a) . 43 27 Flowchart of key functions . . . 45
28 Illustration of proposed digital asthma care process . . . 47
29 Value Creation for each key function . . . 48
30 Value creation for each stakeholder . . . 49
31 Overview main research question . . . 52
List of Tables
1 Data collection overview . . . 252 Interview overview asthma patients . . . 25
3 Interview overview medical care personnel . . . 26
4 Interviews with asthma patients . . . 33
5 Mean values of capitation per listed patient . . . 39
6 Reimbursement per visit . . . 39
7 Comparison costs - physical and digital health care . . . 40
Acknowledgments
First, we would like to thank Doktor24 for giving us the opportunity to conduct our thesis at Doktor24. More specifically, we would like to thank our supervisor Daniel, for the continuous engagement and support throughout the thesis process. We would also like to thank Jonathan och Sanne for their expertise and guidance on chronic diseases and digital health care solutions.
We would further like to thank our supervisor, Henrik Blomgren, at the Royal Institute of Technology, KTH for his assistance and advice from start to finish.
Lastly, we would like to thank all survey participants, and interviewees who took their time to share their experiences and knowledge with us!
Clara Calmered and Josefin Kullman Stockholm, May 2019
Abbreviations and Glossary
Abbreviations
ACG Adjusted Clinical Groups ACT Asthma Control Test
AHCC Asynchronous Health Care Communication CNI Care Need Index
COPD Chronic Obstructive Pulmonary Disease EHR Electronic Health Record
IPU Integrated Practice Unit PHCC Primary Health Care Center PHI Patient Health Information
TDABC Time-Driven Activity-Based Costing
Glossary
Spirometry
A spirometry is a common pulmonary function test used to measure how much air you inhale and exhale. The test is often used to diagnose asthma and COPD.
1 Introduction
In this chapter, the context of the thesis is presented. The section starts with background and problem formulation, followed by purpose and aim, along with the defined research questions.
Lastly, delimitation and contribution to science is discussed and presented.
1.1 Background
Digital health care services in various shapes have emerged in Sweden during the last decade.
A digital health care service refers to health care provided through any sort of digital commu- nication between the patient and medical care personnel (McKinsey, 2014). The patient does not necessarily need to visit a physical health care centre, in order to get care. Technologi- cal progress drives the development of digital health services, including home medical devices (Socialstyrelsen, 2018b). Development is driven by patient demand, the health care system requirements and commercial actors within IT.
Digital solutions solve some of the issues within primary care, by decreasing the administrative burden, improving quality of care, increasing efficiency and enhancing patient self-management (Georgeff, 2014). However, health care providers lack the knowledge and information of how the current available digital technologies can help patients’ needs.
Today, almost half of the Swedish population has a chronic disease and 25% has two or more.
According to (Läkartidningen, 2018), the expenses of chronic diseases constitute around 80- 85% of the country’s total health expenses. The costs of chronic disease management have increased in Sweden, due to a growing population and an increased life span (Läkartidningen, 2018). Chronic disease management requires constant care and medication, during a longer period of time, often a lifetime (Pearce, 2018). Another contributing factor to increased health care costs, is absent from work due to treatment and disabilities. In Sweden, these costs accrue to the state and there is a significant shortcoming of resources for health care providers (Läkartidningen, 2018).
Today, there is an evident mismatch between the existing health care system and the actual disease burden. This since the health care system is formed based on acute disease management, rather than chronic care (Pearce, 2018).
1.2 Problem Formulation
Currently, the primary health care center (PHCC) is the basis for Swedish chronic disease care (WHO et al., 2008). The PHCC is financed by the regions, where capacity depends on the population and size of the region. As a consequence the quality of care might vary across regions. Additionally, some hospital departments have established smaller clinics for chronic diseases such as diabetes, allergy, asthma and heart failure (WHO et al., 2008).
The existing health care system was developed with acute diseases in mind (Kvedar et al., 2016), with solutions intended for interventions or at least, shorter periods of time. The difference between acute diseases and those of chronic characteristics lies in how chronic disease patients need personalized and long-term treatment and care.
In an open study completed by (Socialstyrelsen, 2015b) on the current existing health care for those chronically ill, about 83% of patients with an acute disease claimed that they have access to the health care that they need. In comparison, 75% of the participating chronic disease patients fully or partially agree, to the statement that they currently have access to the health care that they need. Evidently, there is a discrepancy between the chronic disease patient need, and existing health care system offerings.
Pwc conducted a survey in 2016 on the general thoughts of digitalization within health care.
The study concluded that two thirds of the participants believed that digital communication such as video conference calls could, at least partially, replace in-person visits to a doctor (Pwc, 2016) and three in five respondents believed digital solutions improves care for chronic disease patients. Currently, the majority of existing general digital health care services do not have a specific offering for chronically ill patients. This poses the same problems as today’s discrepancy between chronic disease management and the existing health care system, where the digital health care services are designed based on the needs of acute disease patients.
It is essential to take advantage of the paradigm shift and improve the digital chronic care, based on the actual needs of the chronic patients. Patients preferences vary due to the charac- teristics of the specific chronic disease, such as consequences and external factor impact. The treatment processes, medication plans and required guidance and supporting services, differen- tiate between different chronic diseases. Furthermore, some chronic diseases normally develop at an older age, while other chronic diseases are inherent. As mentioned, PHCC is the basis for chronic care diseases. However, the specialist care might be responsible for the chronic care process depending on factors such as the severity of the condition (WHO et al., 2008).
Most chronic diseases are similar in characteristics such as treatment time period, the close connection to unhealthy lifestyles and the need of recurring medication. Diseases such as dia- betes, rheumatism and asthma do however vary when it comes to specific needs and treatment plans. Tracking and analyzing disease symptoms may for example be of great importance for all three, but it has to be executed differently.
Above formulated problems establish the background for the thesis, and the following purpose and aim.
1.3 Purpose and Aim
The purpose of the thesis is to identify improvement areas in the physical asthma care process and propose digital health care functions based on patient requirements.
The aim is to suggest value adding services for Doktor24, in order to attract and care for asthma patients.
1.4 Research Questions
The purpose of the thesis is simplified in the below formulated main research question. From the main research question, the three following sub-questions have been deduced.
Main RQ: How can an existing digital health care service provide an additional service for asthma patients, which satisfies the patient needs?
RQ1: Patient purpose of medical care visits
RQ2: Improvement areas within the current asthma care process RQ3: Opportunities with a digital health care service
1.5 Delimitation
The thesis concerns Sweden and the Swedish health care system, when assessing the current chronic disease process and management. Furthermore, the results are analyzed and discussed with respect to Doktor24, a digital health care provider.
The research questions are answered based on the results in the pre-study, where the results indicated asthma as the most suitable chronic disease to implement digitally. Thus, the final results and conclusions refer to asthma. The study concludes on the chronic care process for the already diagnosed patient, including analysis on the long-term treatment plan, rather than investigating a potential diagnosis.
1.6 Contribution to Science
While there exists research on how digital solutions enable improved care processes and em- power patient self management, literature is insufficient within the field of chronic disease management and particularly asthma. The thesis combines previous research with empirical findings centered on the patient requirements and Doktor24. Moreover, the thesis identifies improvement areas within the physical health care system. Insights and general considerations are provided for a digital service designed for asthma patients, and specific functions preferred by the patients.
1.7 Disposition
Chapter 1, Introduction
In this chapter, the context of the thesis is presented. The section starts with background and problem formulation, followed by purpose and aim, along with the defined research questions.
Lastly, delimitation and contribution to science is discussed and presented.
Chapter 2, Pre-Study
This chapter contains a pre-study, which serves as background when answering the research questions. The results conclude that asthma is the current chronic disease most suitable for a digital solution. The chapter contains a section on the Swedish health care system and its infrastructure, which is followed by an introduction of the digital health care provider Doktor24. Next, is a presentation of the chronic diseases in Sweden and the specific chronic disease Asthma.
Chapter 3, Literature Review
The literature review is based on previous relevant research within three main theoretical fields.
First, the concept of value based health care is presented, determining the structure of this thesis. Thereafter, a background of digital health care is provided, followed by in-depth sections on communication, mHealth applications and data protection security. This is followed by the aspects of self management and how it improves quality of asthma care.
Chapter 4, Method
In the chapter covering the method, research approach and design is presented and discussed.
All research process components are explained and stakeholders introduced. Lastly, quality of research design is considered.
Chapter 5, Results
In this chapter, all results are presented starting with the asthma patient survey results, fol- lowed by the patient and medical care personnel interviews, and a reimbursement and cost analysis for Landstinget.
Chapter 6, Analysis and Discussion
This chapter discusses the results, based on the two main themes in the literature framework;
physical asthma care and digital asthma care. The aim is to analyze the results and found research in accordance with the three research sub-questions.
Chapter 7, Conclusion
The conclusion chapter presents answers to the research questions and final conclusions. It
further discusses the thesis’ contribution to academia and industry, and aspects of sustainability and limitations of the study.
2 Pre-Study
This chapter contains a pre-study, which serves as background when answering the research questions. The results conclude that asthma is the current chronic disease most suitable for a digital solution. The chapter contains a section on the Swedish health care system and its infrastructure, which is followed by an introduction of the digital health care provider Doktor24.
Next, is a presentation of the chronic diseases in Sweden and the specific chronic disease Asthma.
2.1 Background Setting
The Swedish Health Care System The Swedish health care system is decentralized, and man- aged by the regions, local authority or municipality. Sweden consists of 290 municipalities and 20 regions, where the government role is to set the political agenda for health and medical care (Health care in Sweden, 2018). In Sweden, health and medical care is distinguished by public care and private care, where public care is managed by the regions. Private care is managed by a private company, where some companies are in contract with the Swedish National health care Services (Socialstyrelsen, 2018a). As a consequence of the decentralized system, the health care quality might differ across regions.
2.1.1 Doktor24
Doktor24 is the brand of Aleris X AB, which is s digital health care provider, founded in 2016 (Doktor24, 2019). Doktor24 operates in Sweden, Denmark and Norway and offers ser- vices to multiple providers, public health care regions and private insurance companies. Dok- tor24 assists patients through chat, voice calls or video conference call. Doktor24 aids more than thousands of patients each month, where 60% of all visits are solved online (Doktor24, 2019).
Doktor24 has developed a chat bot, as the first step in analyzing the patients’ symptoms.
Through the chat bot, the patient describes the symptoms and responds to questions regarding current health status. Based on the responses, the patient is either recommended a digital consultation or a physical visit at a health care center. When physical consultation is required, the patient is appointed a visit at a primary care center via Doktor24’s app.
2.2 Chronic Diseases in Sweden
There is no conventional medical definition of a chronic disease (Socialstyrelsen, 2015b), how- ever it is characterized by a long-term condition, often a lifetime. The Swedish government decided on an initiative to improve and develop the chronic care, in order to prevent and treat chronic diseases. The initiative is divided into three focus areas; patient based care, knowledge based care and prevention (Socialstyrelsen, 2015b). First, patient based care aims to involve the patient and focus on the individual patient’s needs. Patient based care also advocates co- ordination and communication among and within the different health care providers involved in the treatment process (Socialstyrelsen, 2015). Secondly, knowledge based care is about im- proving the already existing health care such as treatment strategies. However, it is also about identifying areas where there is inadequate knowledge about a chronic disease. Lastly, pre- vention is essential since an early diagnosis will increase the chance for appropriate treatment.
Chronic diseases are treated and prevented differently (Socialstyrelsen, 2015b).
Today, about 40% of the European population older than 15 years, is diagnosed with a chronic disease (Socialstyrelsen, 2015b). In 2013, 35% of the Swedish population was diagnosed with a
chronic disease or a long-term health condition (SCB, 2013). The number of people diagnosed with a chronic disease increases with age as seen in Figure 1.
Figure 1: Population in Sweden living with one chronic disease (SCB, 2013)
The most common chronic diseases in Sweden are heart diseases, allergies, asthma and Chronic Obstructive Pulmonary Disease (COPD), diabetes, high blood pressure, cerebrovascular disease (stroke), rheumatism and arthritis. As seen in Figure 2, the most common ones are allergies, high blood pressure, rheumatism and arthritis, and Asthma and COPD.
Figure 2: Summary of the most common chronic diseases in relation to the Swedish population
Heart diseases, diabetes, high blood pressure and rheumatism and arthritis are all chronic diseases where total number of diagnoses increases by age. Asthma and COPD, and allergies are evenly distributed between different age groups. Furthermore, asthma and allergies correlates and one may trigger the other (Socialstyrelsen, 2015b).
Figure 3: Summary of chronic diseases in relation to the Swedish population, and with respect to age
2.2.1 Asthma
Asthma is one of the most common chronic diseases in Sweden, where the diagnosis between the age groups are evenly distributed. Asthma is cared for in PHCCs, where the care process has improvement potential in terms of optimization (Doktor24, 2019a). It is furthermore a process which can be digitalized in comparison to the other chronic diseases, with the use of wireless medical technological devices and reduction of physical consultations. There is currently a limited supply of digital health care services for asthma patients, while demand is growing. The results of the pre-study and discussion with Doktor24, conclude that asthma is the current chronic disease most suitable for a digital solution, with respect to the nature of the thesis.
Asthma is a chronic disease caused by inflammation of the air passages in the lungs, causing the nerve endings in the airways to become easily irritated. In an asthma attack, it is hard to breathe and usual symptoms are coughing, wheezing and chest tightness (WHO et al., 2008).
The frequency and severeness of the asthma attacks differ between individuals and depends on factors such as physical condition and type of asthma. Some people experience their asthma as a major problem and an interference with daily activities (1177 Vårdguiden, 2019).
Diagnostics and examination, is usually done by executing a spirometry to measure lung capac- ity. In addition, a written control test for asthmatics called the ACT which aims to examine the asthma disease impact on the health status, is usually undertaken (Viss, 2019). As seen in Figure 4, the asthma impact vary across the regions, which might be due to existing allergens, lifestyle choices and emissions.
Socialstyrelsen introduced new guidelines for asthmatic care in 2015, which aims to improve care, increase resource efficiency and provide guidance on how to better monitor and evaluate the quality of care (Socialstyrelsen, 2015a). The guidelines include diagnostics, medication plans, treatment, rehabilitation, monitoring and symptom assessment (Socialstyrelsen, 2015a).
Socialstyrelsen recommends education and support to asthma diagnosed patients, either indi- vidually or in group. The aim is to reduce emergency visits and absence from work and school, as well as improve lung function and quality of life. The corresponding cost is estimated to be low to moderate per quality-adjusted year of life. Furthermore, an individual treatment plan is suggested for each patient, in order to increase degree of monitoring. The complementary cost is considered moderate per quality-adjusted year of life. Additionally, Socialstyrelsen sug- gests physical exercise, which aims to reduce the risk of breathing problems when exercising (Socialstyrelsen, 2015a).
Socialstyrelsen proposes a target indication, where 95% of the total amount of patients should have low impact on their health status (ACT < 19), with a current figure of 65%. Furthermore, Socialstyrelsen suggests a visit pattern of undertaking a spirometry and an ACT more often than once a year, once a year or at least every three years, depending on the severeness of the asthma (Socialstyrelsen, 2015).
Figure 4: Impact on health status with respect to regions (Socialstyrelsen, 2017)
The guidelines require organizational re-structuring such as care personnel education and new- recruitment. This results in increased short-term costs, due to increased frequency of re- visits, extended inter-professional collaboration and support for physical exercise and nutrition.
However, in a long-term perspective this leads to significant cost reductions due to earlier diagnosis and treatment, and improved monitoring (Socialstyrelsen, 2015a).
3 Literature Review
The literature review is based on previous relevant research within three main theoretical fields.
First, the concept of value based health care is presented, determining the structure of this thesis. Thereafter, a background of digital health care is provided, followed by in-depth sections on communication, mHealth applications and data protection security. This is followed by the aspects of self management and how it improves quality of asthma care.
3.1 Value Based Health Care
This section introduces the concept of value based health care and the components of a trans- formation strategy. The components are broken down and further discussed.
The current health care system has been sustained for decades due to a interlocking structure.
In line with challenges of rising costs and varying quality of service (Porter and Lee, 2013;
Powers, 2018), the health care landscape is radically transforming from traditional health care systems to value based health care (Pinzur, 2015; Miller, 2009). Traditional health care encourages volume and revenue and does not penalize quality and improved outcomes (Miller, 2009). Value based health care is centered on the patient’s need, rather than what physicians do. The aim is to shift focus from volume and profitability of the health care services provided, to maximize patient value. This is managed by achieving highest patient outcome at minimized costs. Patient value is defined with the equation below (Porter and Lee, 2013):
V alue = Health outcomes that matter to patients
Costs of delivering the outcomes (1)
Outcomes and costs are measured over the whole health care cycle, where outcome includes the results for a patient’s medical condition during this period. The cost component is the accumulated care costs for the different treatments required for a patient’s medical condition (Porter and Lee, 2013). A criticism of the model, is how the definition of ’value’ differentiates between stakeholders (Pendleton, 2018).
The value agenda is further a transformation strategy to a high-value health care delivery sys- tem (Porter and Lee, 2013), which primarily affects the patients, provider and payers (Tierney, 2018) as seen in Figure 5.
Figure 5: Value through coordination (Tierney, 2018)
The strategy includes the following six interdependent components (Porter and Lee, 2013);
1. Organize health care based on patient’s medical condition 2. Measure outcomes and patient costs
3. Bundled payments models for full care cycles 4. Integrate care delivery systems
5. Geographic expansion
6. Information technology platform
The six value agenda components have been implemented to various degree in organizations.
It is challenging to implement value based health care in fragmented systems (Flink et al., 2017), and all six components are to be implemented together, in order to reach full potential and value (Porter, 2018).
3.1.1 Organize health care based on patient’s medical condition
A value-based health care model is centered on the patient’s medical conditions for specialty care, and on patient segments for primary care. The model therefore advocates integrated practice units (IPUS), rather than specialty departments and discrete services, which existing health care models are organized around. Diversity and range of patient’s need at today’s primary care, cause complexity in the process of estimating outcome and cost. In order to improve patient value at primary care, IPUs are organized in multidisciplinary teams. These teams are based on patient segments with similar care needs such as specific chronic diseases (Porter and Lee, 2013; Bergenstal, 2008).
IPU members collaborate and work as a team towards a common goal, despite co-location. An IPU is responsible for the full health care cycle of the patient’s medical condition. This means responsibility for outpatient, inpatient, rehabilitative care, supporting services such as pa- tient education, engagement, follow-up, prevention protocols, nutrition and smoking cessation.
Collecting and sharing data among all IPU members, enables the process of measuring pa- tient outcomes, costs and time process. Bergenstal (2008) further characterizes the integrated practice unit as a bridge used to navigate the uncoordinated and non value based approach to chronic care. This is essential when aiming for improved patient value (Porter and Lee, 2013).
Patient volume and patient experience for each medical condition or patient segment, becomes essential in the virtuous circle of value creation. As seen in Figure 6, a significant patient volume results in a rapidly accumulating experience, which is followed by more accurate information and clinical data, leading to process efficiency, improved utilization of capacity etc. The total resources and costs are hence distributed among a greater volume of patients, which decreases resources used or cost per patient. This creates future innovation, accurate results adjusted for risk and improved reputation and health care service, which attracts more patients (Porter and Lee, 2013).
Figure 6: Virtuous circle of value creation (Porter and Lee, 2013)
3.1.2 Measure outcomes and patient costs
The second component in the value agenda is to measure health patient outcomes and patient costs for each patient. Today, health care providers are lacking a standardized approach to patient outcome measurements (Kathol et al., 2018). Regular use of reported patient outcome measures and consistent comparison between providers’ performances, are factors contributing to an improved health care (Black, 2013).
Health patient outcome is evaluated by the outcome measure hierarchy, which divides the patient outcome into three tiers (Porter and Lee, 2013). Tier one concerns outcome degree of health status achieved or retained, including clinical and functional status. Tier two is the time recovery process, based on diagnostic errors, ineffective care, treatment complications and additional treatment. Tier three is sustainability of health and recovery, where long-term clinical and functional status are two essential factors (Porter and Lee, 2013).
Figure 7: The outcome measures hierarchy (Porter and Lee, 2013)
It is common that health care providers have cost-accounting systems that are department- based rather than patient-based (Porter and Lee, 2013). This leads to insufficient information about total cost, provided for a particular medical condition. Patient costs are the actual resources used, rather than patient charges. Time-driven activity-based costing (TDABC) is applied when estimating cost for each activity in the health care cycle (Porter and Lee, 2013;
Keel et al., 2017). This cost method is simple and quick to implement, and easy to update (Özyürek and Dinç, 2014). In addition, TDABC is useful for achieving cost reductions and increased patient value. Identified actions for cost reductions include elimination of non-value added services. The focus is to optimize the total care cycle cost rather than minimizing costs of individuals services. Resource efficiency is optimized by minimizing time spent by physician for less skilled activities. Additionally, reduction of service fragmentation and duplication by using existing resources such as physicians and facilities (Porter and Lee, 2013). Keel et al (2017) suggests that the use of TDABC should be gradually incorporated into existing systems, in order to better capture the cost of care delivery for conditions.
3.1.3 Bundled payments for full care cycle
Fee-for-service, episode-of-care, traditional capitation and comprehensive care payment are four common payment systems within health care. The five factors which mainly drive health care costs impact the payment systems differently (Miller, 2009). These five factors are; prevalence of a particular health condition in a population, number of episode of care related to a particular medical condition, number of services and types provided for a medical condition of a patient, the different types of processes, including devices and drugs and lastly the prices of each process, device and drug used in the treatment (Miller, 2009). Shih et al (2015) argues that bundled payments can curtail health care costs while simultaneously improve overall quality of care.
Fee-for-service is a payment model, where the patient pays a predetermined amount for each service received (Miller, 2009). The fee-for-service model is driven by increasing volume rather than increasing quality and patient outcome (Miller, 2009; Porter and Lee, 2013). This means that the health care provider will receive the payment regardless of the patient outcome. The risk with a fee-for-service model is that it encourages fragmented care, with little incentive for collaboration across units and multiple providers (Shih et al., 2015).
Episode-of-care is based on a single price covering all services required during an incident of care (Miller, 2009). The amount which the provider will receive is dependent on the severity of the incident. In case there are multiple providers within an episode of care, a bundle payment is preferred as it seeks to align and compromise the interests of providers (Shih et al., 2015;
Ederhof et al., 2018). Episode-of-care is a flexible model since the provider is able to control the necessary services (Miller, 2009).
Traditional capitation is characterized by a single payment covering the included services during a fixed period, regardless number of episodes of care provided (Miller, 2009). The fixed time period enables the health care provider to control the number of services. In comparison, the episode-of-care model and the traditional capitation model are models which are not based on the patient’s severeness. This could discourage health care providers to provide care to patients having multiple and advanced medical conditions (Miller, 2009).
Comprehensive care payment is placed in between episode-of-care payment and traditional capitation. Comprehensive care payment is based on a single payment during a fixed time period, covering all services provided during this period. The payment amount depends on the patient’s health status, as well as other aspects. It encourages providers to take care of patients with more serious conditions (Miller, 2009).
The mentioned payment systems solve the issues of cost and quality differently. Best suited payment system depends on the amount and variation of cost per episode as well as the frequency of episodes per condition. Providers could use a combination as well as multiple payment systems for different medical conditions and patients (Miller, 2009).
A fee-for service payment is driven by increasing volume, whereas a bundled reimbursement price model encourages health care providers to increase patient value (Miller, 2009; Porter and Lee, 2013; Shih et al., 2015). According to (Porter and Lee, 2013), a bundled reimbursement payment system is suitable in value based health care. A single price covers the full cycle of care of an acute medical care condition, care of a chronic condition and primary care for a patient segment. In terms of determining the payment amount, there are three basic ap- proaches (Miller, 2009). The payment amount is either based on the price set by the payer, the price negotiated between the payer and the provider, or the price set by the provider (Miller, 2009).
Figure 8: Payment system (Miller, 2009)
3.1.4 Integrate care delivery system
A definition of integration is "the act of making a whole out of parts; the co-ordination of different activities to ensure harmonious functioning" (Gröne et al., 2001). It implies an overall
higher level of quality for the system. Integrated care is an adopted concept, where the aim is to improve the services in relation to quality, patient satisfaction, accessibility and efficiency (Gröne et al., 2001). Integration of care delivery system, is divided into four levels. The first level defines the key services where the provider achieves highest value. This means reduction of number of services provided and establishment of partnerships or affiliations (Porter and Lee, 2013). The second level concerns concentration of volume in fewer locations rather than IPU, with respect to each medical care condition. The third level determines best geographic location for each service, in order to achieve highest value. Choice of location for each service is based on medical condition, acuity level, cost level, resource intensity and convenience. The fourth level is integration across locations of IPU (Porter and Lee, 2013).
3.1.5 Geographic expansion
Health care delivery systems are geographically segregated, where health care providers for particular medical conditions need to expand and reach more patients (Porter and Lee, 2013).
Increased patient value is achieved through increased patient volume in medical conditions or primary care segments, rather than expanding service lines locally or develop new broad line units (Porter, 2018). There are two approaches in the strategy of geographic expansions, where the first approach is a hub-and-spoke model. This means expanding to a new region where a new IPU hub is built or acquired. However, the care personnel will be employed by the parent organization and might rotate among the different geographic locations. The second approach is a clinical affiliation, based on partnership with community providers or other local organizations. The partnership implies use of capacity and facilities of the community providers (Porter and Lee, 2013). The strategy of geographic expansion will however not be further discussed in this thesis since it is excluded from the scope.
3.1.6 Information technology platform
The last component concerns utilization of technology in order to restructure the delivery of health care as well as measure results. More specifically, this requires actions such as (Porter and Lee, 2013):
• Combining and standardizing data definitions
• Interoperability standards to enable communication and accessibility among all involving stakeholders
• Data concerning the full cycle of care
• Architecture adapted to extraction of measurement of outcomes and costs
In comparison to physical health care, digital health care enables improved collaboration and swift information exchange across IPUs. Hence, information technology platform enhances the use of standardized processes for measurement of outcomes and costs between IPUs (Tierney, 2018).
3.2 Digital Health Care
This section presents digital health care and existing digital health care solutions. The section is delimited to relevant research within the field of value based health care models. The main section is followed by in-depth sections on asynchronous communication, mHealth applications and data protection security.
Health care has followed the same patterns of digitalization as most other industries (McK- insey, 2014). The industry has for long relied on information technology as a core utility for operational processes, storing patient information and scheduling payments and visits. In a world where patients use technological devices and consumer electronics, on a daily basis, health care faces new challenges (McKinsey, 2014). The interest among patients, is reportedly growing and in a survey conducted by Harris Poll, on behalf of Salesforce, 59% of all health- insured patients, and 80% of millennials, say that they prefer a primary care doctor who offers a patient mobile app over one that does not (Landi and Innovationgroup, 2016).
Digital health care is a general term referring to the use of electronic communication tech- nologies and tools, which are used to create patient services (Edmunds et al., 2017). Some digital health services are inter-linked with medical care centers such as accident and emer- gency departments or PHCCs. Examples of services are patient portals for booking, follow-up communication and file exchange services (Eschler et al., 2015; Coughlin et al., 2017). Other services focus on health factors linked to lifestyle, and how to improve quality of life (Edmunds et al., 2017). Edmunds et al (2017) list below digital service categories within consumer health care:
• Mobile apps, or mHealth applications designed for mobile devices such as tablets and smart phones
• Websites, where all sorts of health and medicine information is gathered and presented
• Interactive health games, where focus is on positive health behaviors such as nutrition, health food choices and fitness
• Sensor-based tracking systems, which includes wearables or implanted devices tracking respiration or heart rate, blood pressure, breathing patterns and other symptoms
• Health-related social media, including general social communication platforms such as Facebook or informational support sites
• Virtual reality programs, to improve mental and behavioral health and rehabilitation, through virtual programs (Nichol, 2017).
Naturally, some services include multiple of above listed category services in their offering with alterations.
Digital health care services have the potential to improve Swedish health care, especially if developed towards including the patient in the care management. Findings in a technical review on telehealth literature commissioned by the Agency for Healthcare Research and Quality (AHRQ), confirmed evidence on how telehealth generally improves care (Totten et al., 2016).
Telehealth and telemedicine is defined as the electronic exchange of health information between two locations with the aim to improve patient care (IT.gov, 2017). It includes a variety of communication technologies in terms of digital health visits and file exchange opportunities (Edmunds et al., 2017). It was concluded that telehealth reduces waiting times, improves access to care and increases patient satisfaction due to a less time-consuming and costly care process (Totten et al., 2016). The most positive results were found when telehealth was used within chronic care management, when it was used to provide communication or consultation session opportunities to patients in combination with a monitoring function. Remote monitoring of patients with chronic conditions reduces unnecessary hospitalizations and emergency visits. In addition it provides additional data and information in order to customize treatment plans (Totten et al., 2016).
Use of patient health information for analyzing symptoms and behaviors is an important factor in the improvement process of chronic care. First, health care providers can review and analyze patient health data to identify both strengths and weaknesses in the existing care process, and determine possible improvement areas (Petersen, 2016). Second, patients who are given access to their own patient health information (PHI) are more motivated to take responsibility for their
own chronic condition and be actively involved in health decisions (Petersen, 2016). People are in general inclined to overcome technology or cost obstacles if they believe that use of digital health care tools will significantly improve their health (Edmunds et al., 2017).
Examples of electronic communication within health care includes the use of chat, phone and video conference call (Duffy, 2015), information sharing through patient websites (Eschler et al., 2015) and e-mail or secure messaging (Angaran, 2006).
3.2.1 Synchronous and Asynchronous Communication
Any sort of communication occurs either synchronously, (in real-time) or asynchronously (se- quentially). These are defined as below (Smith, 2012):
• Synchronous communication requires all parties involved to be present at the same time, where such communication could be a phone call, a physical meeting or a video conference call.
• Asynchronous communication has the advantage of enabling all parties to take part in the communication on a time which is convenient for them. Examples include email, instant messaging or file sharing.
Wilson (2003) defines asynchronous health care communication (AHCC) as "interpersonal, computermediated communication between providers and their patients for telemedicine and e-health functions". While communication between providers and their patients always have been of importance, the connected world has resulted in new patient requirements and demands in terms of how and in which situations they prefer to communicate (Wilson, 2003).
The use and balance of the two communication strategies have become crucial in the transi- tioning from traditional to digital health care. Asynchronous communication in health care includes adoption of patient websites or portals. Providers and patients are given the oppor- tunity to interact through a digital platform to manage health care needs such as prescription renewals, receiving test results, calendar reminders and secure messaging (Eschler et al., 2015;
Ammenwerth et al., 2012). Previous studies indicate a potential to improve patient satisfac- tion by using these services, especially patients with chronic conditions (Eschler et al., 2015).
Patient portals are patient-centered health care information systems, normally linked to a pa- tient’s electronic health record (EHR) (Ammenwerth et al., 2012). It provides the user with a single website or platform, where all interactions can be made in asynchronous communication.
This provides the users with freedom of movement and time (Coughlin et al., 2017). Besides providing the patients with access to their health records and secure messaging, patient portals offer functions enabling scheduling of appointments, prescription renewals and easy access to education materials (Ammenwerth et al., 2012).
In a study performed by Eschler et al (2015), the purpose was to evaluate patient satisfaction when using patient platforms for chronic conditions. In the study, participants found that asynchronous communication was beneficial as a complement to in-office visits, particularly the communication in between the visits (Eschler et al., 2015). Another found advantage was how asynchronous communication enabled the management of complex family arrangements for parents with children with chronic conditions. In a similar study by Britto et al (2013), parents perceived patient portals as a means of offering communication with care providers, enhancing the parents’ sense of control and giving them additional reassurance.
Even if the overall results indicated positive patient experiences, a few patients mentioned how they were confused whether the responsibility for a follow-up meeting was on them or the care providers. They were led to believe that the follow up was exclusively the providers’
responsibility, which counteracts with the notion that asynchronous communication enables patients to take responsibility for their own condition (Eschler et al., 2015). Additionally, asynchronous communication is not suitable for all patients. Patients with lower levels of
education or language barriers, are less likely to use patient portals (Eschler et al., 2015).
The notion is supported by the findings in a study performed in the US on the attitudes toward electronic communication for health care among patients in the medical safety net, where written communication creates a disparity (Schickedanz et al., 2013). To offer the same opportunities to every patient, potential language barriers ought to be considered when creating and implementing written electronic communication in digital health care services. Goldzweig et al (2013) believes that effort must be made to incorporate the more vulnerable parts of the population.
Patient attitudes towards the use of patient portals and electronic communication are in general positive (Eschler et al., 2015; Britto et al., 2013). Eschler et al (2015) highlight patient prefer- ences as the most important factor in an electronic communication tool. On the same note, a study performed on the user requirements of personal electronic health records in chronic can- cer care in Germany, concluded that general patient requirements focused on user-friendliness and clarity (Baudendistel et al., 2015). Further, digital services designed for patients with chronic diseases incorporate the long-term and periodic phase nature. Patient preferences such as daily routines and a frequent interaction with the provider are to be addressed. The main challenge for implementation is how to adopt patient preferences when designing a patient- centric communication tool (Baudendistel et al., 2015; Eschler et al., 2015). However, health outcomes, cost and utilization are factors in need of consideration in the design and implemen- tation stage (Goldzweig et al., 2013). Ammenwerth et al (2012) further argue that existing documentation is insufficient in supporting the notion that patient portals empower patients and improve patient care.
3.2.2 Digital Asthma Solutions
Electronic communication permits the patient to continuously take part in setting goals and evaluate the current treatment plan. While also reducing the risk of a standardized treatment plan, which might occur due to insufficient individual information (Tinschert et al., 2017).
Furthermore, digital health solutions enable better asthma self management, where informa- tion gathering and monitoring are vital parts to set correct diagnosis and future treatment plans (Vasilateanu et al., 2015). Self monitoring can be enhanced by additional education and information materials, where the increased use of smart phones and tablets facilitates direct information sharing (Vasilateanu et al., 2015; Thuemmler and Bai, 2017).
Monitoring functions include asthma control questionnaires through the digital application (Thuemmler and Bai, 2017) and digital spirometry tests prior to consultation sessions with medical care personnel (Hernandez et al., 2018). A dgital spirometer enables spirometry ex- ecuted at home, where the user exhales air into the turbine. Thereafter, medical care health personnel access the PHI through a smart phone or tablet. It reduces issues in current health care, where the variability in respiratory rates and the rare spirometries are likely contributors to the underdiagnosis of chronic respiratory diseases (Becker and Abrams, 2017). Another example is the potential use of smart inhalers connecting the inhaler and use of medicine to an application. It enables important PHI gathering in order to create a customized medication plans (Thuemmler and Bai, 2017).
Digital health applications should be centered on the patients’ needs and requirements enabling patient empowerment, while satisfying other stakeholders such as caregivers, payers, sponsors and government regulators (Kagen and Garland, 2019).
Studies on current Asthma mHealth Applications
There are several digital health care solutions which includes all or some of the required func- tions (Tinschert et al., 2017) provided through an mHealth application. A number of studies have been conducted on the existing mHealth applications for asthma, evaluating functions through patient and clinician surveys and interviews.
In a study performed by Kagen and Garland (2019) on the existing digital asthma solutions, results showed that caregivers are primarily interested in seeing symptom score results, air pollution and pollen levels. One of their main requirements was a function which provided medication adherence data (Kagen and Garland, 2019). Another study by Schultz (2015) evaluated a mobile-app based solution with notifications to remind patients to track their symptoms and peak flow measurements and take medications. Perception among the partici- pating health care personnel was in general positive, and 94% said "I would recommend such an app to my patients". Also, 86% stated that they believed "Improving adherence could reduce costs". It was furthermore found in a study conducted in 2017, that current mHealth applications in general lack tracking asthma-related parameters through mobile phone sensors.
Hence reducing the full potential of the application in terms of gathering information on symp- toms and medication adherence (Tinschert et al., 2017). Moreover, health care personnel are in general concerned of the security of the data storage (Kagen and Garland, 2019), where existing asthma health applications do not include a confidentiality policy (Huckvale et al., 2012).
Patient perception of existing asthma health care applications differentiates from the clinicians in terms of preferred functions. In general, patients prefer solutions enabling self management and increased patient knowledge (Kagen and Garland, 2019; Tinschert et al., 2017) rather than a focus on the pharmacology management part. Positively perceived applications are services which include access to education materials, calendar notifications and receiving alerts when the asthma deteriorates (Kagen and Garland, 2019). Schultz and Metha (2018) found that patients seemed to show a high level of initial engagement when using the application, however it dropped off once symptoms were controlled (Schultz and Metha, 2018). Engagement increased when symptoms were detected again and the condition seemed to deteriorate (Schultz and Metha, 2018).
Tinschert et al (2017) analyzed four themes in found asthma applications; available functions, applied behavior change techniques, implemented gamification components and general appli- cation quality. Identified functions included education materials, self monitoring functions of symptoms or peak flow values, treatment evaluation and an action plan. Functions enabling improved self management, as requested by patients (Kagen and Garland, 2019; Tinschert et al., 2017). In a similar survey on 103 applications in English for asthma patients, two types of functionality were identified (Huckvale et al., 2012). The first consisted of sources of information and education about the condition, while the second one provided tools for asthma management. Neither of the applications offered both types of functionality, and peak flow calculators questionnaire-based applications appeared to be unreliable (Huckvale et al., 2012).
3.2.3 Data Protection Security
Different interests and needs from the stakeholders creates a complexity when developing and designing a mobile application (Kagen and Garland, 2019). It requires a secure cloud based online data storage, experienced software developers, and marketing which suits the purpose of the mobile application and the target group. In general, it is costly and complicated to create a patient-centric application (Tinschert et al., 2017).
New digital solutions and technologies means an increased flow of information exchange be- tween providers and with the patients. Storage of EHR consists of sensitive personal infor- mation. Each function in a digital health solution requires certain levels of data protection security (Uecker et al., 2003). Research implies a growing pressure on health care providers to use and analyze PHI to improve care processes and share findings with the patients. There is a prevailing limited supply of digital solutions for asthma patients (Schultz and Metha, 2018), and the existing ones are reported to suffer from low quality (Tinschert et al., 2017).
Patients are in general willing to share their PHI for therapeutic and research use, but surveys
and research indicates a need for confirmation of appropriate actions in terms of data access and security, such as encryption (Petersen, 2016). In Sweden, handling of health data and in- formation is regulated by patientdatalagen (Datainspektionen, 2019). Information technology security, as described in SS-ISO/IEC 27000, depends on the three requirements confidentiality, integrity and availability (Ledningsnätverket för Medicinsk Teknik, 2016). Confidentiality con- cerns authentication and the rights to access the information. Integrity confirms the reliability of the information provided, and if it is fabricated. Availability concludes on accessibility and traceability of the shared information (Ledningsnätverket för Medicinsk Teknik, 2016) Commercial medical devices require a CE-classification, which is a European standardized legal framework (Läkemedelsverket, 2014). The classification indicates that the product satisfies quality requirements from the EU directive (MDD). All medical devices are classified according to four different risk levels, ranging from low to high risk. The potential CE-classification is dependent on the risk level for each medical device (Läkemedelsverket, 2017).
• Class I
• Class IIa
• Class IIb
• Class III
Class I are low-risk medical devices, assessed and classified by the manufacturer or an external organ based in Sweden. For medical devices within class IIa, IIb and III, the CE-classification depends on an issued EC-certificate from an external reported and inspected organ in the EU (Läkemedelsverket, 2017).
3.3 Self Management
This section describes self management according to the six components; partnership, action plan, co-morbid conditions, information technology, environmental control and education. Self management is an important aspect in value based health care, and contributes to digital health care and chronic diseases, particularly asthma.
The US Institute of Medicine defines self management as "the systematic provision of education and supportive interventions by health care staff to increase patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem-solving support" (of Medicine, 2004). The idea is to emphasize patient responsibility and expand patient knowledge about the chronic condition to primarily solve current problems in relation to the disease. In addition, prevent future illness by creating a healthy life pattern early in life (Grady and Gough, 2014; Epping-Jordan et al., 2004).
Epping-Jordan et al (2004) provide evidence on how a collaborative process between patients and professionals is beneficial in a long-term perspective.
The increased life span of people and improved clinical care, have resulted in an increasing number of persons living with chronic conditions in Sweden (Läkartidningen, 2018). As a consequence, costs accrued to the government have increased. Self management is a patient- centered strategy for treating chronic conditions, and creating long-term better quality of life for chronically ill patients (Grady and Gough, 2014).
In the 2006 report by GINA, new themes arose such as a change in the approach to asthma management, from a focus on treatment methods and evaluation of severity, to guided self management (?). The report highlights the importance of the relationship between patient and health care provider, with an emphasis on education and set goals for treatment, potentially leading to better living conditions for asthma diagnosed patients. This suggests that the recommended written asthma action plan which includes steps on how to act if symptoms are worsened, should incorporate extended information centered on self management. Pinnock
(2015) proposes that the action plan may be irrelevant in this context, as it does not fully reflect the whole spectrum of issues an asthma patient experiences. She identifies a need to provide better guidance on how to handle individual day-to-day challenges.
Asthma self management requires the patient to be actively engaged and participate in de- cisions of treatment and management. It includes monitoring and evaluation of symptoms with the help of appropriate tech devices, environmental control practices and adherence with pharmacotherapy (Eakin and Rand, 2012). It makes asthma self care complex since it besides including a number of different health care practitioners also requires a motivational aspect.
Pinnock (2015) therefore suggests a whole-system approach to the implementation of self man- agement in routine care. The ultimate success of asthma self management depends on this motivational aspect, which relies and builds on the patients’ perception of their condition.
Non-adherence to asthma self treatment is influenced by the patients’ own doubts about their need for treatment, such as fears about possible short- or long-term effects of treatment (Lycett et al., 2018). These arguments supports the notion that education should be prioritized in the treatment plan (Pinnock, 2015).
Breathing exercise programs ease symptoms and increase quality of life. Evidently, both pa- tients and physicians do not know how to use inhalers properly, and education should hence- forth be included in medical courses (Lee et al., 2011; Cheong et al., 2011). It has been proved that smoking can cause acute asthma exacerbation and reduce lung function and impair the response to medication. Thus, information on the effects on asthma from smoking, and psy- chological support for smoking cessation are vital parts in the asthma management (Nagasaki and Matsumoto, 2013).
Lee et al (1998) describe self management as non-pharmacological management consisting of education, partnership, action plan, the environmental control, and the management of comorbid conditions. While action plan refers to a personalized action plan in accordance with (Pinnock, 2015), and education and partnership to the partnership between specialist health care staff and patient (Eakin and Rand, 2012). Environmental control is the importance of identifying causative allergens to prevent acute exacerbation of asthma (Lee et al., 2011). The two additional components in proposed self management model are comorbid conditions and information technology. Comorbid conditions cause aggravation of severe asthma by either medication or by the diseases themselves. For some medication such as the use of aspirin, the effects on asthma are known, where aspirin can exacerbate asthma as a form of respiratory disease (Lee et al., 2011). For such comorbid conditions, appropriated treatment is important and further research on relationships between these conditions and asthma needed (Boulet and Boulay, 2011). Progress in communication technology, computing power and artificial intelligence adds information technology as a main component in asthma self management (Lee et al., 2011).
Figure 9: Illustration of self management (Lee et al., 2011)
Digital self management interventions increase the effectiveness for asthma self management, as it provides extended opportunities to a personalized treatment plan (Lycett et al., 2018) where one can monitor severe asthma with geolocation and air quality (Lee et al., 2011). It is highly scalable, applied in real time, decrease overall costs while providing consistency in the treatment plan (Lycett et al., 2018). The aim is to decrease governmental costs and create chronic care of higher quality, and thus reduce emergency room visits. Ultimate achievement is to decrease mortality and create better living conditions for asthma ill patients (Eakin and Rand, 2012). Adherence to asthma self management guidelines has proven to be an effective tool to control asthma and hence decrease mortality (Eakin and Rand, 2012). Such adherence is improved by frequent contact with health care staff, such as doctor or specialist nurse where Lycett et al (2012) suggests that these visits could take place digitally.
3.4 Synthesis of Literature
Due to the research gap on digital asthma care and patient-centered strategy models for im- plementation, the literature review provides research separately on these fields. Porter and Lee (2013) describes the value based health care model and a transformation strategy, where all components are optimized in a best case practice. However, in a value based health care model an information technology platform is described as one of six components (Porter and Lee, 2013; Miller, 2009), when for a digital health care solution, the technological platform forms the premises on how to develop the strategic model. There are a number of factors to take into account when designing and implementing a digital health care service. The first element concerns the current physical asthma care process (Porter and Lee, 2013; Miller, 2009;
Tierney, 2018), where strengths and weaknesses need to be identified in order to find improve- ment areas (Petersen, 2016). Secondly, research confirms that digital health care improves care (Totten et al., 2016; Edmunds et al., 2017; Eschler et al., 2015; Vasilateanu et al., 2015;
Hernandez et al., 2018) and increases patient satisfaction (Tinschert et al., 2017; Thuemmler and Bai, 2017; Schultz and Metha, 2018; Kagen and Garland, 2019), while there is a general research gap on the specifics of how improvement is achieved (Ammenwerth et al., 2012). Sev- eral authors further mention the risk with the potential use of a digital health care service, such as unreliable data results (Huckvale et al., 2012) and difficulties in terms of motivating the patients to consistent use (Huckvale et al., 2012; Pinnock, 2015) and the issue of secure information sharing (Kagen and Garland, 2019; Datainspektionen, 2019). Lastly, self manage- ment as a patient-centric strategy in accordance with a value-based health care model (Porter and Lee, 2013) for chronically ill patients contributes on how to accomplish patient satisfaction
