Progress on the diabetes care platform, periods 2–3: adding personalised health plans, Local Admin tools and 2 public Micro-apps

Service user section

The system section that service users can use on their own once they have an account has been continuously improved over the past two periods. We started by adjusting the user flow so that the top menu appears on every page, and by updating the Landing page to display a consistent set of menu items. This makes the system look more like an app and feel more familiar and easier to use.

The health indicator recording system now includes charts showing the levels and changes in each value. Health goal-setting has also been moved to the same page as health indicator recording, and is displayed as goal cards directly linked to the relevant indicators (for example, a goal to reduce HbA1C levels is linked to the HbA1C indicator). Red recommendations appear when the latest indicator value exceeds the standard threshold. In the next period, users were given the ability to edit previous records and enter past measurement dates, in preparation for developing a Dashboard that will allow them to view data by time period.

The health activity page displays activities that correspond to the service user's area code, along with red recommendations for activities that match indicators exceeding the standard threshold. Service users can select activities and record additional details on this page.

The most significant development over these two periods is the system's automatic creation of a personalised health care plan, which is generated anew whenever health indicators are recorded. It can be used as a tool for service users and Local Admins to discuss and plan health care. It can be viewed on a mobile phone, tablet, computer or TV, or printed on paper. Each plan consists of:

• Health information (left side) — name, gender and age, with an avatar adjusted to the person's gender, age and actual body shape; diabetes status level from both the initial assessment and the level adjusted by the Local Admin; daily activity level; health indicators with interpretations compared with the previous record; underlying conditions and medications; muscle status (Sarcopenia); and notes from the service provider, entered by the Local Admin to communicate with the service user.
• Health goals and recommendations for each area — health care goals; nutrition recommendations (food format, recommended energy intake, proportions and food examples, along with precautions based on existing conditions); exercise recommendations (MET-min/week and an exercise plan with examples); physical therapy recommendations for level 4-5 groups; and general behavioural recommendations for everyone.
• Recommended learning materials corresponding to each area of advice. For example, videos about a Low carb diet will be shown only to people who are advised to follow that diet.

To help the system generate more accurate plans, the screening questions have been improved to cover underlying conditions, medications, the screening form for sarcopenia (SARC-F), and the mobility level assessment. Service users and Local Admins are therefore encouraged to gradually return and complete this information. The service user information page has also been improved, with its different functions clearly organised into more attractive sections, each with its own icon.

Local Admin section

The Local Admin dashboard now allows data to be viewed by a selected area code. It shows the number of project participants by diabetes status level, followed by the value of each health indicator. For each person, the data is displayed in a left half (information from the first record) and a right half (information from the latest record). The bar charts in each half are grouped by diabetes status level (1-5), and a table below the charts summarises the change in the proportion of service users at each level before and after, counting only those who have a record for that particular indicator.

In the next period, the Dashboard added the number and proportion of service users who achieved diabetes Prevention or Remission. These are calculated by comparing the diabetes level adjusted by the Local Admin with the level from the initial screening. The service user list can now also be sorted by name, in addition to the existing sort by the date and time the data was entered, to support searches by name.

A mechanism has been added for specifying village names in the service user information section, by selecting the name that matches the Department of Provincial Administration data (mname). This allows the Admin to give each Local Admin more precise access to data for specific villages, and to filter Dashboard data by village name.

Micro-app development

To make it easier for areas to trial or adapt various services to their own workflows, Micro-apps have been developed to offer services from within the system as public versions that can be used immediately without a user account.

Micro-app #1 — Diabetes status assessment adapts the diabetes status assessment system, selecting only the questions relevant to the assessment formula and simplifying some of the answer options. Once users have completed the questions and submitted their answers, they immediately receive their assessment results and recommendations, just as they would in the regular system. This information is stored in the database without identifying the user, for further research. If users want to save their results for follow-up, the system will recommend that they log in to the member section as usual.

Micro-app #2 — Blood test results and health information interpretation allows users to enter basic information and whatever blood test values they know. The system uses the same interpretation mechanism as the internal system to indicate whether there is a problem and what it is, without storing personally identifiable information. The health information entered is stored for further study and analysis.