Self-Management of Complex Chronic Patients: Needs and A Proposal

Abstract

Patient self-management plays an important role in an effort to deal more e ectively with chronic conditions helping shifting resources into the community. This paper addresses self-management of complex chronic patients. General needs resulting from the literature are described together with concrete needs from the CONNECARE project. Finally, a proposal based on services, currently adopted in clinical trials running in 3 sites (Lleida, Israel, and Groningen), is presented.

Keywords

• self-management chronic patients patients' monitoring service-based architecture clinical studies

Introduction

Chronic disease is the major cause of disability, the principle reason why patients visit physicians, and the reason for 70% of health care expenditures [ 25 ] [ 2 ]. Current healthcare systems, designed early in the last century to cope with acute disease, did not change when chronic disease became the major issue [ 26 ]. As a consequence, discontinuity and fragmentation of care are widespread. Community and home-based care are poorly developed. Costs mount without obvious commensurate bene ts for patients. A large segment of the population is unable to obtain appropriate health care. Integrated care models are designed to respond to such challenges, through defragmentation of health and social care systems, promotion of collaboration and continuity among care settings, and a move from institutional, reactive care to a home-based, patient-centred, preventive model.

In this scenario, facilitating new forms of active participation by patients and consumers in the collection of personal health data will improve the quality of care delivered to patients through better diagnoses and targeted therapies. In that direction, patient self-management plays an important role, especially when patients are elderly, widowed, and/or with economical-social restrictions [ 50 ]. Many works have been presented in the literature on the subject of selfmanagement of chronic disease and there is the evidence that e ective selfmanagement has a major impact on physical and psychological health status [ 14 ]. Two distinct approaches characterize existing research: (i) investigating remote management tasks relevant to speci c chronic diseases [ 46 ] and (ii) identifying e ective coping strategies and di erentiating between coping patterns in response to chronic illnesses [ 42 ].

Under the umbrella of the CONNECARE project1 and with the aim of designing and developing a self-management system for complex chronic patients, rst, we performed a literature review to collect needs and requirements. Subsequently, we performed a co-design phase in which clinicians, technicians, patients and their carers were asked to participate. At the end of that phase, speci c requirements and needs were collected and the system developed. For the sake of scalability and adaptation to changes, from a technological point of view, we adopted a solution based on services [ 56 ] [ 39 ]. The aim of this paper is twofold, from the one side, to discuss needs and requirements of self-management tools for complex chronic patients and, from the other side, to propose our solution currently adopted in in clinical trials running in 3 sites (Lleida, Israel, and Groningen).

The rest of the paper is organized as follows. In Section 2, a literature review on self-management and self-management systems is given to highlight the general requirements corresponding to developing a self-management tool. Moreover, speci c requirements from the CONNECARE project are presented and discussed. Section 3 presents the proposed approach from the general perspective of the adopted software solution and its current implementation. Section 4 ends the paper with conclusions, discussion, and future directions. 2

Needs

The idea of patient empowerment is not new, it was introduced to health care in the 1970s [ 48 ]. Nevertheless, its popularity emerged in the mid 1990s [ 44 ], and became a feasible reality only in 2000s thanks to the advent of Web 2.0 [ 10 ]. In general, strategies to increase patient empowerment have tended to address two aspects of patients' experience [ 45 ]: (1) disease management and (2) relationships with health care providers [ 3 ]. Approaches to increase patient empowerment vary from patient self-management programs [ 32 ], [ 21 ], to promoting patient involvement in treatment decision-making [ 16 ], [ 27 ], to facilitating the physicianpatient interaction [ 30 ], [ 36 ]. 2.1

General Needs

There is not a universally accepted de nition of self-management [ 6 ]. Alderson et al. refers to it as \an inter-disciplinary group education, based on the principles of adult learning, individualized treatment and case management theory" [ 1 ]. On the other hand, in [ 38 ], authors de ne self-management as a treatment that combines biological, psychological, and social intervention techniques, with a goal of maximal functioning of regulatory processes. In contrast, in [ 14 ], authors interpret self-management as the \day-to-day tasks an individual must undertake to 1 http://www.connecare.eu/ control or reduce the impact of disease on physical status.". Accordingly, four kinds of self-management approaches have been identi ed, depending on the role of the patient [ 7 ]: subordinate, structured, collaborative, and autonomous. Subordinate are those tools that provide modest patient discretion through controlling and supervisory technology. Structured tools require more active, though still limited, patient participation. Collaborative ones involve patient drawing on their own knowledge and making decisions jointly with clinicians. Finally, autonomous tools support patients take matters in hand without much participation from clinicians.

Many studies have shown that patients who engage in healthy diet, exercise, or other aspects of self-management have physical bene ts in terms of fewer symptoms, better functional capability, and fewer complications than those who do not in various diseases (e.g., HIV/AIDS [ 15 ], rheumatoid arthritis [ 43 ], asthma or chronic obstructive pulmonary disease [ 4 ], diabetes [ 55 ], and heart failure [ 29 ]). Most relevant studies have examined the association between poor adjustment and poor self-management. On the other hand, there are studies that investigated the connection between good adjustment and engagement in self-management practices. These studies show evidence of a bidirectional association between wellbeing and adherence to self-management regimens. Patients who can maintain good moods seem to be more willing to engage in lifestyle changes, and those who practice self-management behaviours also report improved wellbeing [ 17 ].

Clark et al. [ 14 ] identi ed the main features to give support in chronic diseases by older adults: maintaining exercises and activity levels [ 52 ]; monitoring physical indicators by objective means [ 41 ]; recognizing and responding to symptoms and controlling triggers to symptoms [ 28 ]; drug prescription and follow-up [ 23 ]; maintaining nutrition and dietary recommendations [ 18 ]; giving up smoking [ 33 ]; using strategies to relax and reduce stress [ 51 ]; managing emotions and psychological response to illness [ 17 ]; adapting to work [ 47 ]; interacting with healthcare professionals [ 24 ]; managing alerts and emergencies [ 9 ]; seeking information and using community resources [ 31 ]; and managing relations with signi cant others [ 22 ].

Mobile phones and other mobile information and communication technology applications and technologies hold great potential as a basis for powerful patientoperated self-management tools. They are increasingly recognized by policymakers as a potential medium for supporting self-management of long-term conditions [ 40 ]. Huckvale et al. [ 28 ] performed a systematic review methodology to the assessment of apps for the management of asthma. Seemly, Marcano et al. [ 35 ] performed a study to assess the e ectiveness, cost-e ectiveness, and feasibility of using smartphone and tablet apps to facilitate the self management of individuals with asthma. Focusing on diabetes, Breland et al. [ 12 ] evaluated the extent to which existing self-management apps address the seven self-management behaviours recommended by the American Association of Diabetes Educators (the AADE7TM)2. From a wider perspective, Withehead et al. [ 54 ] performed a sys

2 https://www.diabeteseducator.org/living-with-diabetes/aade7-self-care-behaviors

tematic review to assess the e ectiveness of self-management apps in long-term condition management. Results show the e ectiveness of adoptig mHealth solutions and apps have been enthusiastically adopted by the patients in all the studies. 2.2

Speci c Needs from the CONNECARE Project

CONNECARE is a R&D project aimed at co-designing, developing, deploying, and evaluating a novel integrated care-services model for complex chronic patients with smart adaptive case management and self-management support. The CONNECARE system is a federation of subsystems each devoted to provide a set of goal-oriented functionalities, whose main components are the SelfManagement System (SMS ) and a Smart Adaptive Case Management system (SACM ) for case modelling and execution, speci cally tailored to the healthcare domain3.

According to a co-design approach, generic requirements for the self-management system have been de ned. Moreover, the following activities to be monitored have been considered as the more relevant: 1. Physical activity. Healthy lifestyles, including physical activity, have proven e cacy in the prevention and treatment of many chronic conditions [ 5 ] [ 49 ]. Accordingly, a self-management tool should monitoring walking activity and its intensity through an activity tracker. In CONNECARE, physical activity monitoring is done by relying to o -the-shelf activity trackers. In particular, the following parameters have to be monitored: steps, distance (km), calories, and minutes of activity by intensity. 2. Questionnaires. In the literature, several questionnaires have been de ned and are currently applied to monitor the status of a given patient in terms of, for instance, anxiety and depression, quality of life perceived pain, selfcare, and mental disorder. To empower patients is important to give them the possibility to ll one or more questionnaires. Once lled a questionnaire, the patient has to receive a suitable message with the corresponding result. At the same time, the professionals have to be automatically informed on the lled questionnaire. 3. Health-status. As also pointed out in the literature, to better follow-up the status of a patient, several vital signs should be monitored depending on the disease and the associated co-morbidities: temperature; blood pressure; heart rate; weight; blood oxygen saturation; blood glucose level; and ECG. In particular, the professional should prescribe when and with which frequency to make the measurement, as well as put thresholds to monitor anomalies. In so doing, both the professional and the patient will receive alerts in case a given threshold has been overcome. 4. Simple tasks. Apart from rehabilitation in hospitals and specialized centres, clinicians agree that daily life activities performed at home radically

3 The SACM is out of the scope of this paper. In the following, we will refer to it only

if necessary for the sake of clari cation of the overall description. improve patients' recovery. With this aim, clinicians want to prescribe simple tasks to be performed during the day (e.g., dancing, cooking, reading). Moreover, depending on the disease and the kind of patient (e.g., in case of elderly people) the professional may ask to perform healthy activities such as drinking or eating a fruit. Through the self-management system, the patient can accept or reject the request and inform when the activity has been performed. 5. Drug prescription. Chronic patients are used to take several drugs during the day. Forget to take any may provoke serious problems. Thus, the professional need to prescribe all the drugs to be taken and the patient will receive a reminder any time s/he has to take one. 6. Advices and training material. Education is a really important issue to be provided to improve follow-up of a therapy and to empower the patient. Thus, the professional can select advices and training material in form of text, images, or videos and the patient is asked to see it. 7. Virtual visits. Several studies show the role of professionals and carers in supporting patients, especially when remote solutions have been adopted. [ 20 ]. Thus, apart providing direct communication via a textual messaging system, in CONNECARE also virtual visits have been considered as a basic functionality to be provided. In so doing, patients may stay more safely at home without needs to move to the hospital any time a recall visit is needed. 3

A proposal

With the aim of providing self-management to chronic patients {the ultimate goal being patient's empowerment{, we propose a solution based on services. The corresponding system, installed in the patient's smartphone, allows the patient to monitor her/his activity, receive recommendations to improve the treatment and to be encouraged in following it, access to her/his data and information, as well as communicate to the medical sta in charge of the case. According to a closed-loop approach (see Figure 1), it is the medical sta who prescribes any kind of task to be performed by the patient. Data gathered by the interaction of the patient with the system (automatically through the devices or manually through direct input) are sent to the cloud where are processed and analysed in order to give the corresponding information to both patient and professionals. In fact, on the one hand, an activity performed by the patient may require automatic recommendations to be sent to her/him. On the other hands, anomalies or low-adherence may require generation of speci c alerts to be sent to the patient for her/his empowerment as well as to the professionals for better follow-up. In so doing, keeping informed the professionals about the treatment follow-up gives the possibility to change something in case of worsening of the health status of the patient, preventing and avoiding re-hospitalization. Moreover, in case high improvements are registered, informing the professionals could help in better follow-up reorganizing the care plan, if needed. 3.1

The

service-based System Figure 2 sketches the overall service-based architecture. It is composed of a set of services each of them in charge of performing a simple task. Complex tasks may be achieved by the collaboration, interaction, and coordination of one or more simple services. When changes are needed in a service, they do not a ect the rest of the system. Moreover, when a new functionality is required, a new service (or set of services collaborating together) is de ned and simply added to the system. In so doing, the proposed solution is robust to changes and improvements.

For locating services, with the purpose of load balancing and fail-over of middle-tier servers, Net ix-Eureka service discovery is adopted4. Eureka is a REST based service for locating services with the purpose of load balancing and failover of middle-tier servers (the Eureka Server). Eureka also comes

4 https://github.com/Net ix/eureka

with a client component (the Eureka Client), which makes interactions with the service much easier. The client also has a built-in load balancer that does basic round-robin load balancing.

As a front door for all requests from the app installed in the patient's smartphone and the services, we rely on Net ix Zuul 5. Zuul is the front door for all requests from devices and web sites to the backend of the Net ix streaming application. As an edge service application, Zuul is built to enable dynamic routing, monitoring, resiliency and security. Zuul uses a range of di erent types of lters that enables to quickly and nimbly apply functionality to the edge service. These lters help performing the following functions: authentication and security, identifying authentication requirements for each resource and rejecting requests that do not satisfy them; insights and monitoring, tracking meaningful data and statistics at the edge in order to give an accurate view of production; dynamic routing, dynamically routing requests to di erent backend clusters as needed; stress testing, gradually increasing the tra c to a cluster in order to gauge performance; load shedding, allocating capacity for each type of request and dropping requests that go over the limit; and static response handling, building some responses directly at the edge instead of forwarding them to an internal cluster.

Management of roles, rights, authentication control, and login is implemented by relying on Spring Cloud Security6. It o ers a set of primitives for building secure applications and services with minimum fuss; as well as a declarative model which can be heavily con gured externally (or centrally) lends itself to the implementation of large systems of co-operating, remote components, usually with a central identity management service.

Right now, for all the functionalities listed above but \virtual visits" a suitable service has been de ned and developed. Moreover, 5 additional services have been provided to give support and prove further functionalities: { Patient's monitoring services

Physical activity. Given a prescription, the service automatically calculates the adherence day by day and sends recommendations to the patient and feedback to the case manager. Two families of activity trackers are currently integrated in the system via the Third party service (see below): the Fitbit wristbands and smartwatches by Nokia/Withings. Questionnaires. The following o -the-shelf questionnaires have been implemented in the corresponding service to: follow-up anxiety and depression (Hospital Anxiety and Depression Scale (HAD) [ 57 ]); evaluate the condition of patients with osteoarthritis of the knee and hip (The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) [ 37 ]); assess quality of life (SF-12 [ 53 ] and EQ5D [ 13 ]); measure the perceived pain (S-LANSS [ 8 ]); evaluate self-care (Barthel index [ 34 ]); and self-report in case of mental disorder (TiC-P [ 11 ]). Moreover,

5 https://github.com/Net ix/zuul/wiki

6 https://cloud.spring.io/spring-cloud-security/

suitable questionnaires for self-care, health-status, asthma control, illness perception, and self-assessment have been properly de ned inside the project.

Health status. Medical devices from by Nokia/Withings have been integrated in the system via the Third party croservice (see below). Moreover, the patient may manually add a measure taken with a device without connection. The patient receives a reminder any time s/he has to take a measurements. Collected data are stored in the self-management system to be accessed by the patient for revision as well, as sent to the professionals for follow-up.

Simple tasks. The following activities may be prescribed to be performed by the patient at home: straightening and bending the knee while lying on the back; keeping the leg away from the body while lying on your back; lifting the pelvis lying on the back with bent legs; lifting the leg upright while lying on a side; bending the knee and bringing it to the stomach while lying on the back; bending the knee in the sitting; bending the knees standing with the back to the wall; straightening and bending the seated knee; getting up from the chair and sitting back; walking outside at moderate speed; up and down stairs; strengthening the thigh; strengthening the elbow, buttocks, and ngers; training session for physiotherapy; drinking water; easting a fruit; playing cognitive games; and visiting a nurse at the clinic.

Drug prescriptions. The CONNECARE project involves 3 countries: Spain, Israel, and The Netherlands. Accordingly, the service aimed at following-up drug prescriptions is connected to the lists of drugs available in the corresponding hospital information systems in the 3 countries. In so doing, the professional may select the drugs to be prescribed from an granted list. The patient receives that prescription and con rms when s/he takes it. In case of low adherence a message is sent to both patient and professional.

Advices and training material. Each clinician in charge of a case may select a document, video, image to be shared to the patient for consultation. The patient may create her/his own list of bookmarks to have a direct access to relevant information any time is needed. { Supporting services

Noti cations. This service receives the noti cations generated by any of the rest of services and which recipient is the patient (e.g., a new prescription has been generated). Through the Noti cations service, the corresponding message is sent to the app for its visualization. Moreover, complex noti cations that come from the interaction with the patient's monitoring services may also be sent. In fact, a reminder is sent before any required task (e.g., 15 minutes before taking the blood pressure) and a con rmation given after any performed task with suitable information (e.g., the value of the blood pressure).

Alerts. Monitored data are continuously analysed at runtime. As soon as a patient's monitoring service nds an anomaly, it interacts with the Alerts service and a suitable alert message is sent to both the patient to be aware of the issue and the clinical sta to be informed and act accordingly. In particular, anomalies are triggered any time data gathered from the patient (e.g., through the medical devices or a questionnaire) exceeds a given threshold de ned at prescription time (e.g., a critical heart rate value).

Recommendations. All data gathered by the devices worn by the patient are automatically analysed to give an intelligent support. The Recommendation service provides suitable recommendations to patients. In particular, this service is designed and developed to provide support to patients in each of the required tasks. Both a distributed and central solution is adopted. On the one hand, each patient's monitoring service will contain its own recommender system. On the other hand, thanks to the interaction and collaboration of all the patient's monitoring services, advanced recommendations could be given aimed at giving support at a broader level. Currently, a speci c recommender system for physical activity support has been de ned and designed. The description of the recommender system is out of the scope of this work, the interested reader may refer to [ 19 ].

Third party. In order to provide patients' monitoring, also the integration with third parties elements, such as wearable and medical devices, has be considered. This service has two main functionalities: managing the connections to the external providers and the standardization of the data model. By using standard communication and authorization protocols, such as OAuth7, data shared by the patient from these third parties can be gathered. The service saves all the connection information and hide the details to the services that need information from them. Regarding the standardization of the data model used inside the system, each third party uses its own data model to obtain the information from them but this service transform the model to a common model used by all the connected third parties. In this way, the services only have to ask for the information to the third party connector and wait for a wellknown message with the data of the patient without to worry about the communication process and the di erent data model used. In so doing, the Third party services works as an abstraction layer.

Messaging. This service o ers a bidirectional communications tool that allows patients to interact with the member of the medical sta in charge of the case. Similar to the well-known Whatsapp app, patients may send/receive text, images, videos, links, and documents. 3.2

The Current Prototype

The corresponding self-management system is an app currently available on the markets (both Android and iOS are supported). It is currently adopted in clinical

7 https://oauth.net/

studies started in May 2018 in Lleida, Israel, and Groningen. At writing moment, about 30 patients are using the self-management system and are monitored by the corresponding clinicians.

The current version of the app implements the rst 4 monitoring functionalities listed above: physical activity, questionnaires, health status, and simple tasks. Figure 3 shows some screenshots of the current prototype. 4

Discussion and Future Directions

Researchers on patient's self-management agree with Clark et al. on the main features that a self-management tool has to implement to give support in chronic diseases by older adults. In the EU project CONNECARE, following a co-design approach, professionals, technicians, and patients de ned the requirements of a self-managament system aimed at empowering complex chronic patients. Most of the features identi ed by Clark et al. have been listed also in CONNECARE: maintaining exercises and activity levels; monitoring physical indicators by objective means; recognizing and responding to symptoms and controlling triggers to symptoms; drug prescription and follow-up; using strategies to relax and reduce stress; managing emotions and psychological response to illness; interacting with healthcare professionals; managing alerts and emergencies; and seeking information and using community resources. Starting from these requirements, a technological solution based on the concept of services has been de ned and developed. The corresponding system is currently running in 3 sites (i.e., Lleida, Israel, and Groningen) throughout real implementation studies. About 30 patients are using it.

Future work is planned following three directions: 1) from the backend perspective, the service for providing virtual visits is under de nition; 2) from the front-end point of view, the app is under development to include the drug prescription and the advices and technical material services; and, 3) for the sake of evaluation, after the studies patients will be asked to answer to the User Experience Questionnaire.

Acknowledgments

The study was partially funded by the European Community under H2020EU.3.1. - Societal Challenges - Health, demographic change and well-being programme, project grant agreement number 689802 (CONNECARE). Special thanks to all the clinicians that participated in the co-design process, the volunteers that tested the system, and the patients that are participating in the studies.

References

1. Alderson , M. , Starr , L. , Gow , S. , Moreland , J.: The program for rheumatic independent self-management: a pilot evaluation . Clinical rheumatology 18(4) , 283 { 292 ( 1999 )

2. Anderson , G. : Partnership for solutions. chronic conditions: Making the case for ongoing care . 2002 . robert wood johnson foundation and john hopkins university ( 2003 )

3. Aujoulat , I. , dHoore, W. , Deccache , A. : Patient empowerment in theory and practice: polysemy or cacophony? Patient education and counseling 66(1 ), 13 { 20 ( 2007 )

4. Bailey , W.C. , Kohler , C.L. , Richards , J.M. , Windsor , R.A. , Brooks , C.M. , Gerald , L.B. , Martin , B. , Higgins , D.M. , Liu , T. : Asthma self-management: do patient education programs always have an impact? Archives of Internal Medicine 159 ( 20 ), 2422 { 2428 ( 1999 )

5. Barberan-Garcia , A. , Gimeno-Santos , E. , Blanco , I. , Cano , I. , Mart nez-Pall , G. , Burgos , F. , Miralles , F. , Coca , M. , Murillo , S. , Sanz , M. , et al.: Protocol for regional implementation of collaborative self-management services to promote physical activity . BMC health services research 18 ( 1 ), 560 ( 2018 )

6. Barlow , J. , Wright , C. , Sheasby , J. , Turner , A. , Hainsworth , J.: Self-management approaches for people with chronic conditions: a review . Patient education and counseling 48(2) , 177 { 187 ( 2002 )

7. Barrett , M.J.: Patient self-management tools: An overview . California HealthCare Foundation ( 2005 )

8. Bennett , M.I. , Smith , B.H. , Torrance , N. , Potter , J.: The s-lanss score for identifying pain of predominantly neuropathic origin: validation for use in clinical and postal research . The Journal of Pain 6 ( 3 ), 149 { 158 ( 2005 )

9. Bodenheimer , T. , Lorig , K. , Holman , H. , Grumbach , K. : Patient self-management of chronic disease in primary care . Jama 288 ( 19 ), 2469 { 2475 ( 2002 )

10. Bos , L. , Marsh , A. , Carroll , D. , Gupta , S. , Rees , M. : Patient 2.0 empowerment . In: SWWS. vol. 97 , pp. 164 { 168 ( 2008 )

11. Bouwmans , C. , De Jong, K., Timman , R. , Zijlstra-Vlasveld , M. , Van der FeltzCornelis , C., Tan , S.S. , Hakkaart-van Roijen , L. : Feasibility, reliability and validity of a questionnaire on healthcare consumption and productivity loss in patients with a psychiatric disorder (tic-p) . BMC health services research 13 ( 1 ), 217 ( 2013 )

12. Breland , J.Y. , Yeh , V.M. , Yu , J. : Adherence to evidence-based guidelines among diabetes self-management apps . Translational behavioral medicine 3(3) , 277 { 286 ( 2013 )

13. Brooks , R.: EuroQol: the current state of play . Health Policy 37 ( 1 ), 53 {72 (Jul 1996 )

14. Clark , N.M. , Becker , M.H. , Janz , N.K. , Lorig , K. , Rakowski , W. , Anderson , L. : Self-management of chronic disease by older adults: a review and questions for research . Journal of Aging and Health 3 ( 1 ), 3 { 27 ( 1991 )

15. Collins, R.L. , Kanouse , D.E. , Gi ord , A.L. , Senter tt , J.W., Schuster , M.A. , McCa rey , D.F., Shapiro , M.F. , Wenger , N.S.: Changes in health-promoting behavior following diagnosis with hiv: Prevalence and correlates in a national probability sample . Health Psychology 20 ( 5 ), 351 ( 2001 )

16. Davison , B.J. , Degner , L.F. : Empowerment of men newly diagnosed with prostate cancer . Cancer nursing 20(3) , 187 { 196 ( 1997 )

17. De Ridder , D. , Geenen , R. , Kuijer , R., van Middendorp, H. : Psychological adjustment to chronic disease . The Lancet 372 ( 9634 ), 246 { 255 ( 2008 )

18. Evert , A.B. , Boucher , J.L. , Cypress , M. , Dunbar , S.A. , Franz , M.J. , Mayer-Davis , E.J. , Neumiller , J.J. , Nwankwo , R. , Verdi , C.L. , Urbanski , P. , et al.: Nutrition therapy recommendations for the management of adults with diabetes . Diabetes care 37(Supplement 1) , S120{S143 ( 2014 )

19. Fernandez , J.M. , Mamei , M. , Mariani , S. , Miralles , F. , Steblin , A. , Vargiu , E. , Zambonelli , F. : Towards argumentation-based recommendations for personalised patient empowerment . In: International Workshop on Health Recommender Systems, co-located with ACM RecSys 2017 ( 2017 )

20. Fernandez , J.M. , Sola , M. , Steblin , A. , Vargiu , E. , Miralles , F. : The relevance of providing useful information to therapists and caregivers in tele* . In: Information Filtering and Retrieval. DART 2014 : Revised and Invited Papers ; C. Lai , A. Giuliani and G. Semeraro (eds.) , vol. 668 , pp. 97 { 117 ( 2016 )

21. Foster , G. , Taylor , S.J., Eldridge , S. , Ramsay , J. , Gri ths, C.J.: Self-management education programmes by lay leaders for people with chronic conditions . The Cochrane Library ( 2007 )

22. Gallant , M.P.: The in uence of social support on chronic illness self-management: a review and directions for research . Health Education & Behavior 30 ( 2 ), 170 { 195 ( 2003 )

23. Haynes , R.B. , McKibbon , K.A. , Kanani , R.: Systematic review of randomised trials of interventions to assist patients to follow prescriptions for medications . The Lancet 348 ( 9024 ), 383 { 386 ( 1996 )

24. Heisler , M. , Bouknight , R.R. , Hayward , R.A. , Smith , D.M. , Kerr , E.A. : The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management . Journal of general internal medicine 17(4) , 243 { 252 ( 2002 )

25. Ho man, C. , Rice , D. , Sung , H.Y.: Persons with chronic conditions: their prevalence and costs . Jama 276 ( 18 ), 1473 { 1479 ( 1996 )

26. Holman , H. , Lorig , K. : Patient self-management: a key to e ectiveness and e - ciency in care of chronic disease . Public health reports 119(3) , 239 { 243 ( 2004 )

27. Huby , G. , Brook , J.H. , Thompson , A. , Tierney , A. : Capturing the concealed: Interprofessional practice and older patients' participation in decision-making about discharge after acute hospitalization . Journal of Interprofessional Care 21 ( 1 ), 55 { 67 ( 2007 )

28. Huckvale , K. , Car , M. , Morrison , C. , Car , J.: Apps for asthma self-management: a systematic assessment of content and tools . BMC medicine 10(1) , 144 ( 2012 )

29. Jaarsma , T. , Halfens , R. , Tan , F. , Abu-Saad , H.H. , Dracup , K. , Diederiks , J.: Self-care and quality of life in patients with advanced heart failure: the e ect of a supportive educational intervention . Heart & Lung: The Journal of Acute and Critical Care 29 ( 5 ), 319 { 330 ( 2000 )

30. Little , P. , Dorward , M. , Warner , G. , Moore , M. , Stephens , K. , Senior , J. , Kendrick , T. : Randomised controlled trial of e ect of lea ets to empower patients in consultations in primary care . bmj 328 ( 7437 ), 441 ( 2004 )

31. Lorig , K.R. , Holman , H.R. : Self-management education: history, de nition, outcomes, and mechanisms . Annals of behavioral medicine 26(1) , 1{ 7 ( 2003 )

32. Lorig , K.R. , Sobel , D.S. , Ritter , P.L. , Laurent , D. , Hobbs , M.: E ect of a selfmanagement program on patients with chronic disease . E ective clinical practice: ECP 4 ( 6 ), 256 { 262 ( 2001 )

33. Lorig , K.R. , Sobel , D.S. , Stewart , A.L. , Brown Jr , B.W. , Bandura , A. , Ritter , P. , Gonzalez , V.M. , Laurent , D.D. , Holman , H.R. : Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial . Medical care pp. 5 { 14 ( 1999 )

34. Mahoney , F.I. , Barthel , D.W.: Functional evaluation: the barthel index: a simple index of independence useful in scoring improvement in the rehabilitation of the chronically ill . Maryland state medical journal ( 1965 )

35. Marcano Belisario , J.S. , Huckvale , K. , Green eld , G., Car , J. , Gunn , L.H. : Smartphone and tablet self management apps for asthma . The Cochrane Library ( 2013 )

36. McCann , S. , Weinman , J.: Empowering the patient in the consultation: a pilot study . Patient education and counseling 27(3) , 227 { 234 ( 1996 )

37. McConnell , S. , Kolopack , P. , Davis , A.M.: The western ontario and mcmaster universities osteoarthritis index (womac): a review of its utility and measurement properties . Arthritis care & research 45(5) , 453 { 461 ( 2001 )

38. Nakagawa-Kogan , H. , Garber , A. , Jarrett , M. , Egan , K.J. , Hendershot , S. : Selfmanagement of hypertension: Predictors of success in diastolic blood pressure reduction . Research in nursing & health 11(2) , 105 { 115 ( 1988 )

39. Namiot , D. , Sneps-Sneppe , M. : On micro-services architecture . International Journal of Open Information Technologies 2 ( 9 ), 24 { 27 ( 2014 )

40. Patrick , K. , Griswold , W.G. , Raab , F. , Intille , S.S. : Health and the mobile phone . American journal of preventive medicine 35(2) , 177 { 181 ( 2008 )

41. Peel , E. , Douglas , M. , Lawton , J.: Self monitoring of blood glucose in type 2 diabetes: longitudinal qualitative study of patients' perspectives . Bmj 335 ( 7618 ), 493 ( 2007 )

42. Rakowski , W.: Health psychology and late life: The di erentiation of health and illness for the study of health-related behaviors . Research on aging 6(4) , 593 { 620 ( 1984 )

43. Riemsma , R.P. , Taal , E. , Kirwan , J.R. , Rasker , J.J.: Systematic review of rheumatoid arthritis patient education . Arthritis care & research 51(6) , 1045 { 1059 ( 2004 )

44. Saltman , R.B.: Patient choice and patient empowerment in northern european health systems: a conceptual framework . International journal of health services 24(2) , 201 { 229 ( 1994 )

45. Samoocha , D. , Bruinvels , D.J. , Elbers , N.A. , Anema , J.R ., van der Beek, A.J.: E ectiveness of web-based interventions on patient empowerment: a systematic review and meta-analysis . Journal of medical Internet research 12(2) ( 2010 )

46. Siafakas , N. , Vermeire , P. , Pride , N.a. , Paoletti , P. , Gibson , J. , Howard , P. , Yernault , J. , Decramer , M. , Higenbottam , T. , Postma , D. , et al.: Optimal assessment and management of chronic obstructive pulmonary disease (copd). the european respiratory society task force . European Respiratory Journal 8 ( 8 ), 1398 { 1420 ( 1995 )

47. Sivarajan , E. , Newton , K. , Almes , M. , Kempf , T. , Mans eld , L., Bruce , R.: Limited e ects of outpatient teaching and counseling after myocardial infarction . Heart and Lung: Journal of Acute and Critical Care 12 ( 1 ), 65 { 73 ( 1983 )

48. Tomes , N.: Patient empowerment and the dilemmas of late-modern medicalisation . The Lancet 369 ( 9562 ), 698 { 700 ( 2007 )

49. Vargas , C. , Burgos , F. , Cano , I. , Blanco , I. , Caminal , P. , Escarrabill , J. , Gallego , C. , Llauger , M.A. , Miralles , F. , Solans , O. , et al.: Protocol for regional implementation of collaborative lung function testing . NPJ primary care respiratory medicine 26 , 16024 ( 2016 )

50. Vargiu , E.: From healthy to happy ageing: the power of self-management . In: AI*AAL.it 2017 . Arti cial Intelligence for Ambient Assisted Living . Proceedings of the Third Italian Workshop on Arti cial Intelligence for Ambient Assisted Living , CEUR proceedings Vol 2061 , ( 2018 )

51. Vattano , A.J. : Self-management procedures for coping with stress . Social Work 23 ( 2 ), 113 { 119 ( 1978 )

52. Warburton , D.E. , Nicol , C.W. , Bredin , S.S.: Health bene ts of physical activity: the evidence . Canadian medical association journal 174(6) , 801 { 809 ( 2006 )

53. Ware , J.E. , Keller, S.D., Kosinski , M. : Sf-12: How to Score the Sf-12 Physcial and Mental Health Summary Scales . QualityMetric Incorporated ( 1998 )

54. Whitehead , L. , Seaton , P. : The e ectiveness of self-management mobile phone and tablet apps in long-term condition management: a systematic review . Journal of medical Internet research 18(5) ( 2016 )

55. Williams , G.C. , McGregor , H.A. , Zeldman , A. , Freedman , Z.R. , Deci , E.L. : Testing a self-determination theory process model for promoting glycemic control through diabetes self-management . Health Psychology 23 ( 1 ), 58 ( 2004 )

56. Wol , E.: Microservices: Flexible Software Architecture . Addison-Wesley Professional ( 2016 )

57. Zigmond , A. : Hospital anxiety and depression scale (had) . Seishinka Shindangaku 4 , 371 { 372 ( 1993 )