Patient care is often spread across multiple specialists at different clinics or hospitals who do not communicate regarding overall care of the patient. Fragmented health care and information systems often lead to lost referrals, missed follow-ups, and delayed treatments, negatively impacting patient outcomes.

Patient tracking involves monitoring patient progress across different levels of care. Efficient patient tracking is critical for continuity of care, particularly for patients requiring specialist referrals and frequent follow-ups. A real-time, integrated tracking system can enhance care coordination, reduce administrative burden, and improve overall healthcare efficiency. Healthcare providers frequently struggle with tracking patient progress across different levels of care. Siloed paper-based or electronic health record systems, and inconsistent communication among primary care providers, specialists, and hospitals contribute to systemic inefficiencies.

The stakeholders include both patients and medical professionals. Patients deal with redundant tests, missed appointments, and poor care coordination. Primary care doctors, specialists, nurses, and administrative staff struggle with inefficient tracking and referral processes. Health care systems experience inefficient and ineffective workflows.

Under the National Digital Health Mission, the Ayushman Bharat Health Account provides patients with a unique identifier to track their records across different healthcare providers. The implementation varies between states, with greater adoption among government health facilities. However, the majority of diabetes care is provided at private health facilities, where electronic and paper-based records are siloed.

Many healthcare providers rely on fragmented systems, including handwritten notes, spreadsheets, or separate digital platforms. Some hospitals use electronic health records (EHRs) with referral tracking but interoperability between systems is often lacking. Follow-ups are frequently managed manually, relying on phone calls and paperwork, which leads to delays and inefficiencies.

Capturing Patient Journeys: A platform for diabetes care coordination, with focus on specialist referrals and follow-up.

Additional Considerations: There are several additional considerations involved in long-term patient monitoring. The platform should be compatible with existing EHRs and hospital management systems, provide real-time tracking of referrals and follow-up, works across multiple devices (smartphones, computers) with varying levels of connectivity, software and hardware configurations, and follow the national standards on health data security.