West Green Surgery wanted to improve the identification and management of diabetes and hypertension in its patients. In November 2017, the practice had a National Diabetes Audit (NDA) achievement of 37% and 28% of patients had poorly-controlled hypertension. The practice had spent much clinical and administrative time recalling all diabetics/hypertensives through telephone/letter in a non-prioritised alphabetical approach, but many continued to miss appointments. Software was developed that recalled patients more efficiently while educating them about their most recent results. It analysed the disease registers and sent personalised messages to patients informing them of their latest health values, comparing them with previous, urging medication compliance, providing URL links to health information or directing them to make an appointment to see an appropriate clinician. The software used protocol-driven artificial intelligence to determine poor/good control, tailor advice and direct patients accordingly. Patients have become more empowered with their own health data and more actively engaged in their health management. The software also analysed the practice’s database, identifying patients at risk of diabetes (HbA1c 42-47).
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