Chronic disease management is highly complex because multiple interventions are required to improve clinical outcomes. From the patient’s perspective, his main problems are dealing with self-management without support and feeling isolated between clinical visits. A strategy for providing continuous self-management support is the use of communication technologies, such as the telephone. However, to be efficient and effective, an information system is required for telecare planning and follows up. The use of electronic clinical records facilitates the implementation of telecare, but those systems often do not allow to combine usual care (visits to the health clinics) with telecare. This paper presents the experience of developing an application called SIGSAC (Software de Información, Gestión y Seguimiento para el Autocuidado Crónico) for Chronic Disease Management and Telecare follow up.
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机译：慢性疾病管理非常复杂，因为需要多种干预措施才能改善临床结果。从患者的角度来看，他的主要问题是在没有支持的情况下进行自我管理以及在两次临床就诊之间感到孤立。提供持续自我管理支持的策略是使用通讯技术，例如电话。但是，为了高效有效，远程护理计划需要信息系统并进行跟踪。电子临床记录的使用促进了远程医疗的实施，但是这些系统通常不允许将常规护理（访问医疗诊所）与远程医疗相结合。本文介绍了开发用于慢性病管理和远程护理后续应用的名为SIGSAC（软件信息，Gestióny Seguimiento para el AutocuidadoCrónico）的经验。
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