To identify recent technology trends, platform development cases, and usability and effects of ICT-based chronic disease management in older adults, we reviewed a total of 60 articles (23 on hypertension, 18 on diabetes, and 19 on heart failure) indexed in the PubMed database. The rapid increase in research on the management of chronic diseases through ICT since 2009 has been attributed to technology development. The consultation systems mainly used web or mobile-based online platforms or single-application technologies. In most studies, both patients and medical staff participated. For hypertension and diabetes, ICT-based chronic disease management led to significant reductions in blood pressure or blood sugar levels.^7-10) In the case of heart failure, faster communication between patients and medical staff improved patient satisfaction and reduce hospitalized costs.^11-13) However, little research has been conducted on a consultation service model between the medical staff of different institutions (Supplementary Table S2, Fig. S1).

Between June 4 and 28, 2018, FGIs were conducted with 6 medical staff (2 acute care hospital physicians, 2 long-term care hospital physicians, 1 acute care hospital nurse, and 1 long-term care hospital nurse), 1 patient, 2 family members, and a hired caregiver. Most of the interviewees indicated that inter-institutional consultation is not well-established in Korea; however, due to complex multi-morbidities among older patients, there is a strong need for coordinated management between institutions. In addition, due to the absence of common geriatric evaluation tools, communication regarding functional status is impossible between institutions. Therefore, these FGIs underscored the importance of a common format for the comprehensive assessment of multi-morbidity, medication, nutrition, and functional status for efficient information sharing. In addition, the participants indicated that an online consultation system would be helpful for the management of duplicate drugs and chronic diseases. To activate the ICT-based, inter-professional consultation system, the physicians indicated the need for reimbursement for the invisible resource input provided by personnel. Meanwhile, patients or family members indicated that they would be willing to pay for an ICT-based consultation system that substituted for regular outpatient care without having to visit a university hospital or large center. They also expressed hope that the sharing of medical information between institutions would be more convenient with the ICT-based system.

The FGI revealed the difficulties in evaluating and managing older patients while the qualitative literature review identified the usefulness of ICT-based management or consultation services in older patients. To collect and request more specific opinions and components to be included in the ICT-based management and consultation service system, we conducted an on- and off-line structured survey from August 16 to September 30, 2018, of 114 medical staff and 50 patients/family members/caregivers. Among the 114 medical staff (53% male) who participated in the structured survey, 80% were physicians and 20% were nurses; 45% belonged to tertiary hospitals and the others to LTCH and NH. Most medical staff (94%) had over 1 year of experience in managing older adults. Among the 50 patients/family members/caregivers respondents, 76% were family members, 18% were hired caregivers, and 6% were patients.

The most difficult factors in the management or care of older patients were complex multi-morbidity (4.1/5 points), absence of assessment tools and reimbursement systems for older patients (4.04/5), management of duplicate medications (3.96/5), lack of information about previous medical records (3.93/5), and lack of information about patient’s pre-morbid function (3.90/5) (Fig. 1). The most common information transferred at the time of referral to other institutions was medical certificates and prescription and medical records; laboratory results or imaging files were relatively lower in necessity. The respondents most frequently reported using paper (86.8%) to transfer medical information but reported being dissatisfied (2.6/5) with the amount, quality, and methodology. Medication and chronic disease management were among the services expected to be provided by the ICT-based management service. Among chronic diseases, the demand for management services was high in the order of diabetes, hypertension, and heart failure. In addition, as a management method, consultation on acute exacerbation, provision of the latest guidelines, and cumulative inquiry of results were preferred. However, the participants also expressed concerns about the lack of an adequate reimbursement system (4.33/5) and leakage of private or medical information (3.61/5). The types of rehabilitation services that most needed to be provided in the ICT-based service were swallowing, physical function, and cognitive rehabilitation.

Patients visited an average of 1.55 hospitals and met 2.66 physicians, with 42% having a history of transfer. The average travel time for outpatient/emergency visits was 1.72 hours, with an average cost of $41.22 per person. Depending on the patient’s place of care, the greatest cost and time was required for the transfer of older patients living in NH or LTCH. We observed a positive response that the sharing of medical records through the ICT-based service would be helpful for treatment (4.16/5), prevention of duplicate prescription or drug abuse (4.26/5), increased convenience of delivering medical information (4.14/5), and money and time saving (3.92/5). Similar to the medical staff survey results, there were also concerns about the leakage of private or medical information (3.42/5). Regarding their willingness to pay for the ICT-based management and consultation system, we received above-average positive answers (3.50/5) from patients, family members, and caregivers.

The ICT-based management and consultation service model was developed to provide proper high-priority services for the medical staff of LTCH or NH. The detailed contents of the service model were identified through a literature review, FGIs, and structured surveys (Fig. 2).

Since the healthcare workers in LTCH in Korea assess patient general function, comorbidity status, and cognitive status monthly to claim specified daily fees for care service, we developed CGA based on these data. The medical information exchange system is used to transfer information on prescribed medications, diagnoses, laboratory data, and vital signs from the electronic medical records (EMRs) of LTCH to the service platform. The CGA integrates (1) existing medical information received from EMRs of LTCH and (2) additional evaluated data required for disease management or rehabilitation services. A CGA encompassing the 6 domains of comorbidity, physical function, swallowing function, cognitive function, activities of living, and medication was developed to be administered to patients when they are initially included in the Health-RESPECT service platform. Physical function is evaluated by activities of daily living (ADLs) and instrumental ADLs (IADLs) with modified Barthel Index and Lawton and Brody Index.^14,15) Cognitive, swallowing, and physical functions are evaluated using the Korean version of the Mini-Mental State Examination (K-MMSE), the Standardized Swallowing Assessment (SSA), and the Functional Ambulatory Category (FAC), respectively.^16-18) Different versions of the MMSE (MMSE-K) used in long-term care facilities are substituted as needed. We used a validated self-report frailty questionnaire, based on the Korean version of the fatigue, resistance, ambulation, illnesses, and loss of weight scale (K-FRAIL).¹⁹⁾ On the basis of Beers criteria, 2016 SNUBH Inappropriate Medication for Elderly Criteria, and guidelines for chronic diseases, a list of drugs inappropriate for older adults was developed to fit for their clinical significance and frequencies of clinical use in NH and LTCH.^20-24)

On the basis of the results of the CGA, we also developed an individualized challenge list and treatment targets that included chronic disease management (hypertension, diabetes, and heart failure), drug management, and rehabilitation (cognitive, swallowing, and physical functions). The drug management service was developed by screening the medication currently prescribed and providing the number and identity of drugs matching those on the absolute or potentially inappropriate drug lists each month.

The treatment targets for chronic diseases were set according to the patient frailty status (Table 1). A chronic disease management service was developed to provide information about recommended and non-recommended combinations of medications, screening, responses to adverse events during treatment (orthostatic hypotension, hypoglycemia), drug adjustment according to renal function, comorbidity screening and management (diabetes-dyslipidemia), guidance for acute decompensated conditions, and lifestyle modifications based on recent guidelines.^21-23)

In the rehabilitation service, video clips of exercise and swallowing rehabilitation of various levels are provided once weekly according to patients’ physical and swallowing function, as evaluated by FAC or SSA. For example, patients who were non-functional ambulatory or ambulatory dependent on physical assistance (FAC 0–1) are provided with videos of pressure sore prevention or sitting exercises through correct posture while patients who could ambulate independently are provided with videos of more intensive exercise. The cognitive rehabilitation program was developed for increasingly difficult orientation, attention, memory and problem-solving training in which patients with MMSE scores of 10 or more and 21 or less participated three times weekly.

The Health-RESPECT service has a system for issuing warning alarms by message and written consultation service between institutions for vital or laboratory findings outside of the normal ranges or if the medical staff wish to do. Additionally, videoconferencing with acute care hospitals allowed regular management of patients living in LTCH or NH and participating in the Health-RESPECT service model (Fig. 3). Although the medical staff of long-term care facilities are responsible for primary decision-making, patients who may require changes in their assessment or prescription plans can be discussed bi-directionally through alarm messages, written consultations as needed or monthly video-conferencing.

To determine the expected clinical feasibility and usability of the various functions and tools included in the Health-RESPECT platform, we collected expert opinions from prospective users (medical staff from acute care hospital or long-term care facilities), who provided positive feedback, especially for the chronic disease and drug management tools. Additional corrections were made to the parts shown in these evaluations to be too complex or unusable.