Abstract
Background: Chronic non-communicable diseases require long-term care to mitigate complications, particularly in cases of specific conditions, such as hypertension. This study underscores the significance of consistent treatment and care, specifically within the context of hypertension. Methods: The objective of this study was to develop an integrated Electronic Health Record (EHR) system model, which would incorporate annual physical check-ups and medical care history assessments within hospital settings. Once the model was established, its application was expanded to quantify the outcomes in hypertensive patient care. Additionally, the model's effectiveness was assessed through in-depth interviews and focus group discussions conducted in community hospitals. Results: Within the cohort of 10,385 participants, 1,980 (19.07%) exhibited normal health, while 8,450 (80.93%) required ongoing care due to pre-existing health conditions. Notably, 7,459 (88.74%) of those requiring care actively engaged with the continuous care system. After adjusting for age, gender, history of hypertension, history of dyslipidemia, and increasing body mass index (BMI), it was observed that adherence to hypertensive continuous care was 0.37 times more likely in males compared to females, a history of hypertension was 0.10 times more likely compared to those without a history of hypertension, a history of dyslipidemia was 0.39 times more likely compared to those without such a history, and each unit increase in BMI was associated with a 1.17 times of adhering to continuous care. Moreover, the qualitative study revealed additional dimensions of the model's importance, including its user-friendliness, the value of appointment reminders, and notifications for blood sampling. Additionally, the study highlighted limitations related to accessing information from major hospitals. Conclusion: This study demonstrated the effectiveness of the EHR model in enhancing health outcomes. However, it emphasized the importance of sustained treatment and vigilant monitoring. While the model positively impacted patient care, the role of expert medical guidance remained pivotal for effective hypertension management. The study stresses the ongoing need for refining the model to optimize its advantages.
