Digital health integration for noncommunicable diseases: Comprehensive process mapping for full‐life‐cycle management

To create a systematic digital health process mapping framework for full‐life‐cycle noncommunicable disease management grounded in key stakeholder engagement.

Organization's (WHO's) emphasis on holistic system and service integration. 12Such fragmentation and insufficient stakeholder engagement hindered the smooth incorporation of digital technology into NCD management. 13,14ocess mapping, synonymous with patient journey or journey modeling, was a person-centered approach that had arisen in academic research in the past decade.It delved into the procedural and experiential dimensions of service processes, tracking stakeholders' navigation of healthcare systems and spotlighting key interactionsreferred to as touchpoints-with various agents, professionals, and technologies. 15,16This methodology illuminated health navigation experiences, aiding the refinement of services and identification of care gaps. 17This methodology had been applied in several studies to explore digital technology's role in health care.A 2020 review showcased touchpoints in the journeys of patients with NCDs in LMICs, emphasizing digital technology's impact on holistic NCD management. 18Blasiak et al. 3 detailed the integration of digital health interventions with patient engagement.A 2022 study explored artificial intelligence (AI)-enhanced patient journeys, targeting equitable resource utilization and improved patient experiences. 19Maas et al. 20 introduced a cyclical hospital service process for patients with chronic illnesses and identified digital touchpoints to bolster current practices.
Although progress had been made, significant gaps in digital health care remained unaddressed.A comprehensive, digitized system spanning the entire NCD management life cycle had yet to be outlined, and disjointed digital efforts combined with rigid workflows impeded healthcare evolution.Furthermore, the more robust engagement of key stakeholders, an essential element in process mapping and digital health design, was required. 21In this study, a systematic digital health process mapping framework for full-life-cycle NCD management grounded in key stakeholder engagement was delineated.Rather than improving on existing strategies, this framework was developed with the aim of informing future digital transitions.In this article, we used the term "process mapping" instead of "patient journey," recognizing that while patient-centered care was integral, we also aimed to incorporate the benefits and insights of other stakeholders in NCD management practices.This "person-centered" approach ensured broader acceptance of relevant policies and strategies. 20

METHODS
Process mapping was performed in this study using an optimized lean methodology 22 to overcome the inherent limitations of systematism and standardization associated with this technique.A triphasic qualitative approach encompassing a literature review, stakeholder focus group discussions, and expert consultations anchored in the consolidated criteria for reporting qualitative research was implemented from August 2022 to June 2023 in Shanghai, China. 23This semisystematic strategy has been proven to be reliable and effective. 24,25

Desk research
In the initial phase, we formed a scientific team composed of healthcare managers, health supervisors, and those working in informatics, intentionally excluding core decision makers to minimize leadership pressure.We established clear project aims, roles, and responsibilities for better alignment and efficiency.The scientific team employed a desk research approach to scrutinize extant policies, guidelines, and exemplary practices in the domain of digital NCD management through structured and unstructured inquiries.The former consisted of a search of six databases (PubMed, Embase, MEDLINE, BIOSIS, Wanfang, and HowNet) to identify relevant literature from the past decade.
The latter involved the review of resources such as the Incidence & Prevalence Database, WHO portal, relevant health ministries' sites, clinical guidelines, and Google to bridge any informational voids. 24The desk research findings were documented diligently to underpin subsequent study segments.To facilitate and clarify further digital touchpoint identification, and based on the existing literature, 15,16,18,20,24,26 we divided full-life-cycle NCD management into five stages: awareness and screening, outpatient and inpatient visitation, evaluation and diagnosis, intervention and treatment, and discharge and adherence.

Focus group
In the second phase, focus group discussions were held to subdivide The process of thematic analysis, with an example.
(Figure 1).The second author then conducted a critical analysis 27 to identify prevalent digital touchpoints in the five-stage NCD management process from stakeholders' perspectives.

Delphi consensus
The Delphi consensus method was used to further refine the process mapping framework.Delphi consultation involved two rounds of online meetings with follow-up email interactions.We set a participation quorum of approximately 50% of the total number of focus group participants (n = 10) for each round to ensure wellinformed consensus.We assembled a diverse group of senior leaders in health informatics in top-tier clinical, academic, public, and supervisory bodies to ensure a rich variety of backgrounds and authoritative expertise.
The experts suggested adjustments to the touchpoints (additions, deletions, modifications, mergers, or divisions), and their feedback was integrated into the framework.The revised touchpoints were then circulated among the experts until at least 80% consensus was reached.

Process mapping framework for full-life-cycle digital NCD management
Following the first two study phases, the research team crafted a draft of the process mapping framework with 5 stages, 19 links, and 60 touchpoints (Tables 1-5).A brief description of each touchpoint detailed the digital technology employed, content implemented, and anticipated outcome.

Awareness and screening
This stage, encompassing the preservice period, was focused on the boosting of health awareness, promotion of positive behaviors, and screening for diseases.It was a vital component of full-life-cycle NCD management, with the goal of enhancing overall health and reducing morbidity, that was often overlooked, particularly in LMICs. 28All stakeholder groups acknowledged the need for digitization in this stage; primary care physicians and public health officials underscored Digital technology infusion promised tailored health education via multimedia applications coupled with virtual interaction and psychological support, driving user engagement and fostering healthier lifestyles.The mining of user-generated data from wearable devices and mobile sensors, encompassing social, biomedical, and behavioral biomarkers, enabled precise risk identification, helping public health agencies and primary care professionals to reduce NCD morbidity rates.Furthermore, when NCD symptoms arise, AI-driven models and remote physicians collaboratively provided primary services and triage recommendations, ensuring a seamless blend of primary and specialist medical care.

Outpatient and inpatient visitation
This stage encompassed all preliminary tasks, intermediary occurrences, and ancillary processes (other than actual diagnostic and therapeutic practices) throughout hospital services.Although it was traditionally segmented across various medical discourses, we designated it a distinct stage in the framework because we identified numerous opportunities for digital amalgamation and substantive enhancement potential.Notably, the intricacies and unpredictabil-ity inherent in healthcare systems meant that touchpoints such as scheduling and documentation might recur during service provision.
To foster coherence and minimize superfluity, the discussion of such touchpoints in this section would not be repeated for stage 3 and  professionals.These enhancements of efficiency and safety allowed these professionals to spend more time on clinical practices, reducing current heavy administrative burdens.
From the perspective of medical providers, a primary challenge had been the redesign and streamlining of hospital services for efficient scheduling and monitoring.Intelligent systems could instantly monitor and evaluated staff, medical tasks, and resources.They facilitated ideal resource distribution, optimal pairing, and activity scheduling across outpatient, emergency, and inpatient services.This feature ensured efficient alignment, reduced peak-time congestion, and enhanced the safety and effectiveness of medical institutions' operations.

Evaluation and diagnosis
In this stage of digital NCD management, the goal was to create intelligent diagnostic platforms.Leveraging digital advancements, robots and AI modules aided in test/examination procedures and abnormality detection, remote platform facilitates telework, and cooperation for technologists.Computer-assisted diagnosis offered intelligent support for diagnostics and risk evaluation, improving decision making about further medical intervention.
Patients with NCDs benefited from streamlined diagnostic access and intelligent interpretation, which increased their health comprehension and improved doctor-patient interactions and treatment compliance.For clinical professionals, digitalization at this stage lightens their workload, improving diagnostic precision and medical safety.
For medical institutions, the integration of automation, monitoring, and traceability refined administrative processes, boosting operational efficiency.

Refined process mapping framework based on expert insight
During the first Delphi consensus round, experts suggested minor adjustments to the touchpoints.They advised the expansion of the "remote consultations" touchpoint, highlighting its role in communication among multidisciplinary professionals, patients, close contacts, and other caregivers, collectively named the "healing alliance."Public health experts introduced an "automated disease reporting" touchpoint that facilitated data transfer to public health agencies, thereby reducing clinician and administrator workloads.One expert questioned the rationality of listing "prescription" as an independent fourth-stage link, considering its digital and practical significance, but this link was retained after clarification.After revision, the refined touchpoints list (Table 6) was sent to experts and secured > 80% consensus in the second round.

DISCUSSION
In this study, a process mapping framework for the comprehensive digital management of NCDs was developed with the incorporation of insights from key stakeholders (Figure 2).The goal of this framework was to holistically integrate digital technology into health care with the addressing of user needs.
The framework was a modified nonlinear model that avoided the flaws of traditional structures, many of which delineated sequential processes along a care continuum pathway with single entry and exit points. 31Real-world NCD management was a complex and fluctuating, and did not comprise a fixed series of events.Factors such as disease Abbreviations: 5G, fifth-generation mobile network; AR, augmented reality; VR, virtual reality.

F I G U R E 2
The process mapping framework for full-life-cycle digital management of noncommunicable diseases.AI, artificial intelligence; EHR, electronic health record.
unpredictability could result in fragmented or cyclical user actions, such as repeated specialist visits and intermittent disease tracking.Our framework was designed to be adaptable, allowing users to engage with and exit from any touchpoint based on their unique circumstances, and to obtain assistance via other touchpoints when using a given touchpoint.
Several existing digital health initiatives align with our framework.
[34] Organizational and cost efficiencies had stemmed from the optimization of triage, bed allocation, and in-hospital logistics. 35Regarding NCD self-management and primary services, digital coaching and educational tools had bolstered user engagement and personalized learning. 36,37Tools such as mobile apps, wearable devices, and digital health diaries had been shown to enhance behavior and management outcomes. 35,36,38,39Additionally, digital technology had been shown to aid risk screening, teleconsultation, and self-diagnosis. 35,40[43] To amplify the impact of digital health and realize our process mapping vision, the intertwining of technologies such as 5G, AI, and big data with the medical sector was essential.This approach would significantly increase healthcare automation, intelligence, and personalization, facilitating the provision and exchange of medical services and expediting the sector's digital transformation. 33Ideally, systems would incorporate active sensing, intelligent analytics, proactive anomaly alerts, decision recommendations, and self-improvement through continuous learning.5][46] Currently, digital tools were used primarily for medical procedures, leaving room for their application for social interaction and emotional support provision.This challenge and opportunity in digital NCD management could be addressed with innovations such as guidance robots, augmented reality, virtual reality, and advanced voice and gesture analyses to provide holistic assistance and emotional support to users. 33,35ring the focus group discussions and Delphi consultations, stakeholders and experts participating in this study highlighted the challenges and barriers faced in digital health.Policy experts and providers underscored the need for a comprehensive digital transformation framework.Presently, digital health evolution was often propelled by specific entities or vendors and focused on particular functions, and thus occurred in the absence of overarching goals and constructional planning. 37Despite global efforts geared toward systematic medical digitization, 47,48 practices often remained fragmented, leading to resource wastage and slow progress.Strategic framework implementation could refine resource utilization and accelerate development.
Other crucial aspects were the technical infrastructure and economic investments, especially in LMICs, which required enhancement. 49The scarcity of resources underscores the value of macro-planning, and a focus on stakeholder benefits could motivate institutions to invest purposefully.
Data inconsistency significantly impaired data quality 50 and hampered digital healthcare development, as reiterated by stakeholders and experts in this study.The variability of data standardization and interoperability across medical institutions complicated the integration, utilization, and sharing of data on patients with NCDs.Although a unified information system seemed to be an ideal solution, its implementation was resource intensive.At present, the establishment and enforcement of sensible data standards were imperative.
Clinicians participating in this study raised concerns about digital health, pointing out the potential for inaccuracies and the risks of medical negligence and legal challenges.Ambiguities in current digital health regulations, encompassing responsibility, data safety, privacy, and ethical issues, also inhibited user adoption, 51 an important consideration for policymakers.
Effective digital technology integration required the adjustment of organizational structures and workflows, as well as the expansion of users' digital capacity.These considerations could lead to "institutional inertia" among providers. 52The addressing of this issue required proper policy incentives and the demonstration of investment returns, which were vital for the boosting of medical personnel's digital skills and for broader digital health adoption.
The current study had some limitations.The identification of touchpoints was qualitative; future research might benefit from quantitative process mining.Although we aimed to cover all common digital touchpoints, areas such as palliative treatment were not addressed, necessitating future adjustments with medical and technological advancements.
In conclusion, the framework developed in this study prioritizes stakeholders' perspectives and provides a systematic approach to digital NCD management.We encourage policymakers to align their digital strategies with this framework for the efficient and future-ready integration of technology in health care.

stage 4 .
Focus group's discussion revealed patients' desire for enhanced digital coordination among individuals, emergency centers, and medical institutions to mitigate acute exacerbation and complications during the prolonged courses of NCDs.They pinpointed areas for the improvement of current services, such as the bridging of information gaps, enhancement of communication, and addressing of coordination challenges leading to delayed treatment.Their concerns also extended to intricate hospital procedures, the opaque medical information sphere, and long wait times.Digital technology interventions promised real-time connectivity and information dissemination across healthcare sectors, as well as streamlined service delivery.Moreover, digital technologies provided patients with assistive tools, tailored education, and feedback channels, bolstering their health comprehension, shortening wait periods, and elevating the efficiency of medical visits, which were vital for patients with NCDs who had frequent healthcare interactions.From the viewpoint of clinical professionals, digital technology offered the potential to seamlessly gather and monitor health data on patients with NCDs, fostering automation and intelligent daily workflows.Moreover, smart devices, interactive interfaces, and robots could facilitate real-time communication and cooperation among Medical intervention encompassed prescription, biological product use, surgery, behavioral therapies, psychological treatments, and other modalities applied with the aim of mitigating NCDs and related risk factors.Focus group's discussion revealed that patients grapple with the intricacy and specialized nature of medical interventions, which impeded full comprehension of the treatments that they received.Rational medication used emerged as another major concern, with patients facing overwhelming medication choices, cryptic package instructions, ambiguous prescriptions, the labyrinth of drug compatibility, and unavoidable medication adjustment intrinsic to chronic disease management.Clinical professionals sought more digital support of decision making, treatment execution, and intervention efficacy assessment.Digital technology had the potential to enhance the whole treatment window, with clinical decision support systems (CDSSs) delivering optimal recommendations, automating tasks, and enabling continuous monitoring throughout medical intervention implementation.Digital educational tools improved understanding, communication, and treatment adherence.Intelligent pharmacies reduced manual tasks and prescription errors, offering continuous remote monitoring and guidance to ensure rational drug use.Collectively, these innovations elevated the quality and safety of medical interventions and operational efficiency of institutions.3.1.5Discharge and adherence This stage encompassed the discharge of patients with NCDs from hospitals, the management of long-term health follow-up after medical intervention, and the handling of comprehensive health data throughout the management cycle.It involved the primary care and public health sectors and elicited numerous complaints, akin to the first stage.

TA B L E 1
Process mapping framework for full-life-cycle digital NCD management.Stage 1: awareness and screening.
1.3.2Remote primary medical services: 5G, AR, and VR technologies enable primary physicians to deliver services such as consultations, preliminary diagnoses, and referral recommendations remotely via smart applications such as hospital internet and VR consultation rooms.Abbreviations: 5G, fifth-generation mobile network; AI, artificial intelligence; AR, augmented reality; GPT, generative pretrained transformer; NCD, noncommunicable disease; VR, virtual reality.its criticality and pointed out the inefficiencies and practitioner burdens stemming from China's traditional NCD prevention methods, and patients expressed the desire for more engaging and informative health guidance.
Process mapping framework for full-life-cycle digital NCD management.Stage 2: outpatient and inpatient visitation.Intelligent emergency calls: wearable and smart devices identify risk signs and initiate automatic real-time calls to emergency centers when urgent symptoms appear or medical help is needed.2.1.2On-sitefirst aid: using GPS, 5G, AR, and VR, rescuers access accident data and environmental risks and alert nearby medical units or volunteers to request aid or remote assistance.2.1.3Rapid emergency transition: intelligent route planning is applied according to GPS positioning, real-time traffic information, and destination to avoid traffic and estimate transit times, ensuring smooth transfers to medical facilities.2.1.4First aid data monitoring: patients' vital signs are monitored in real time using mobile equipment and wearable devices, with emergency data shared seamlessly with rescuers and medical institutions.2.1.5AI-assisted evaluation: using AI and databases, the system evaluates patients' risk and emergency levels based on past health records and real-time data, optimizing first aid decisions.The model can be iteratively optimized via training and machine learning.2.1.6Intelligent rescue resource dispatch: real-time resource allocation optimizes the dispatch of rescuers, vehicles, and healthcare providers based on available rescue resources and patient urgency.Precision appointment scheduling: intelligent scheduling is used to arrange patient visits, tests, and treatments based on patient demands and urgency via digital platforms, with reminders, wait-time estimates, and proactive rescheduling notifications.Intelligent medical records: interacting via text or voice, the system autonomously compiles detailed patient data, creating comprehensive, structured health records.These records are remotely accessible, supporting various clinical needs with visual presentations.2.5.2Automated document verification: this feature ensures medical record integrity by automatically checking documents based on established verification rules, identifying discrepancies and prompting for necessary corrections.2.6 Patient service 2.6.1 Navigation and positioning services: real-time navigation tools, using technologies such as Bluetooth and GPS, guide patients accurately within hospitals.These systems consider individuals' schedules and queue information to propose the most efficient routes.2.6.2Online convenience services: leveraging advanced technologies such as the IoT, the system offers personalized amenities based on patient data and resource availability.Patients can effortlessly schedule appointments online and conveniently access facilities and services.Precision personal scheduling: this system optimizes personnel allocation by analyzing real-time data (e.g., on patient flow, resource availability).It enhances efficiency through smart scheduling and management, considering various operational aspects (e.g., operation plans, human resources status).2.7.2 Intelligent resource management: centralized resource oversight dynamically tracks and manages hospital inventory and equipment usage.It enables precise resource allocation supported by automated transportation via robots for optimal operational flow.Process mapping framework for full-life-cycle digital NCD management.Stage 3: evaluation and diagnosis.Digitally assisted operations: using computer visualization, AI, and sensors, instruments and robots (e.g., for blood sampling and endoscopy) aid laboratory testing and examination.3.1.2Intelligent reporting: using AI and computer visualization, the system enables lesion detection and classification for various tests and examinations.The model can be iteratively optimized via training and machine learning.Reports are auto-generated, with patients able to access and print them and receive AI explanations on multiple devices.3.1.3Automatic monitoring and quality control: automatic, continuous, and dynamic tracking and verification of laboratory tests and examinations occur.Based on data and quality rules, the system identifies irregularities and alerts users to anomalies.Automatic prescription verification: the system checks prescriptions (e.g., for drug compatibility, administration routes), detecting risks and duplicates, and flagging any deviations for pharmacists.4.3.2Smart pharmacy: robotics automate medication dispensing and packaging.Patients receive real-time updates on medication pickup, reminders, and status through various digital touchpoints.After receipt, essential medication information is provided to patients.Process mapping framework for full-life-cycle digital NCD management.Stage 5: discharge and adherence.Rapid discharge: patients can handle discharge processes (e.g., payment, deposit refunding, administration) via mobile devices and interactive screens.The system proactively sends discharge guidance and reminders to patients.5.1.2Electronic documents: patients can view, download, and print documents such as discharge summaries on multiple devices.With consent, these documents are automatically uploaded to insurance systems or reimbursement agencies.Remote prescription and testing/examination: technologies like 5G, the IoT, VR, and blockchain enable remote prescription, laboratory testing, and examination for patients with chronic or routine conditions.EHRs: with automated collection and consolidation of individuals' lifetime health data, personal EHRs are stored securely in the cloud, enabling easy access and sharing.AI and big data analysis are used to conduct and obtain visual simulations, historical comparisons, analytical evaluations, risk prediction, and management recommendations based on users' health status.5.4.2Real-world health database: public health systems merge and structure individuals' EHR data.AI technology, knowledge bases, and big data enable intelligent data processing and analysis and model fitting.5.4.3Data quality and security: health data undergo automated cleansing, standardization, and post-structuration, with discrepancies triggering alerts.Privacy measures, including data encryption and layered permissions, ensure data protection and quality.
TA B L E 2 2.2.2 AI preconsultation: AI-driven collection of patient health data are entered into electronic medical records, which physicians can then access and modify.2.2.3 Electronic check in: upon arrival, patients can check in digitally and receive real-time queue information and wait-time estimates.Re-check in is provided when required to arrange procession reasonably.2.2.4 Intelligent clinics: clinics feature identity recognition, multimedia screens, and assistive robots for enhanced patient experiences, interaction, and communication.2.3 Patient enrollment 2.3.1 Rapid patient enrollment: patients complete hospitalization procedures digitally, with the system auto-collecting relevant data and providing guidance.2.3.2Intelligent hospitalization scheduling: the system plans admission schedules based on patients' health conditions and bed availability, coordinating preadmission tests and speeding up the hospitalization process.2.4 In-hospital care 2.4.1 Mobile ward rounds: ward-round robots and AI assistants conduct real-time ward rounds, collecting and displaying patient data interactively.2.4.2Remote consultation: multidisciplinary experts connect remotely using 5G, AR, VR, and multimedia devices for high-definition MDT consultations.2.4.3Smart nursing: patient identification, medical instruction execution, patient indicator measurement, and form compilation can be seamlessly facilitated through the use of wristbands, bracelets, smart mobile devices, and interactive bedside screens.2.4.4Real-time patient monitoring: monitoring plans are tailored based on patients' diagnoses, treatments, and recovery statuses.Smart devices automatically collect and display data, issuing alerts and activating communication (e.g., nurse call) systems when abnormalities are detected.2.6.3Full-time accompaniment and guidance: intelligent multipath systems such as guiding robots and apps assist patients throughout their medical journeys.They provide customized guidance, educational content, and reminders based on patients' medical plans.2.6.4Personalized satisfaction survey: customized multidimensional surveys are conducted through various digital means to assess patient satisfaction.In case of complaints, the system tracks resolution processes, keeping patients updated on progress and outcomes.3.1.4Remote technologist system: a regional cloud platform enables technologists to remotely access and work on laboratory test and examination results on various devices, facilitating consultations and primary institution guidance.3.2 Evaluation and diagnosis 3.2.1 CAD: the system, powered by AI, knowledge bases, and big data, aids diagnosis by analyzing patients' histories, health data, and test results.Continuous model optimization enhances accuracy.3.2.2Intelligent risk evaluation: by assessing patients' medical histories, symptoms, and test results, the system intelligently evaluates patients' medical risks and conditions.Alerts are triggered when risk factors or severity surpass set thresholds.Abbreviations: AI, artificial intelligence; CAD, computer-assisted diagnosis; NCD, noncommunicable disease.TA B L E 4 Process mapping framework for full-life-cycle digital NCD management.Stage 4: intervention and treatment.4.2.4Intelligent prognosis evaluation and prediction: using patients' health data, risk profiles, and medical interventions, the system employs knowledge databases, big data, and AI to predict outcomes (e.g., potential complications, readmission risk, intelligent assessment of prognosis and recovery stages).5.2.2 Continued medical care: a cloud platform enables collaboration across medical institutions for continued care.Specialized physicians, primary physicians, nurses, and other caregivers provide remote guidance-based continued medical services through the platform.5.2.3 Intelligent follow-up: using 5G, AR/VR, and the IoT, remote follow-up is based on patients' medical conditions and follow-up rules, disease progress, medical plans, and prognoses.Automated follow-up records are synced, with reminders and arrangement of subsequent visits.5.3 Long-term management 5.3.1 Personalized education: patients receive tailored health content via multimedia, big data, and analysis.Services such as health management planning and remote device training are offered, and patients are matched with relevant online communities for emotional support.5.3.2Disease data monitoring: using wearable devices, remote equipment, sensors, and mobile applications, real-time disease data are collected for analysis and prognosis establishment.Deviations trigger proactive alerts, with recommended medical advice provided as needed.5.3.3Self-management: using virtual health coaches, companion systems, and smart apps, patients receive self-management plans driven by AI, big data, and knowledge bases, with ongoing monitoring and feedback.Intelligent devices (e.g., rehabilitation and care robots, remote treatment tools) aid the execution of these plans.
Refined touchpoints in the process mapping framework.Remote healing alliance communication: leveraging 5G, AR, VR, and multimedia devices, the healing alliance engages remotely in high-definition consultations and communication 2.5 Medical records 2.5.3Automated disease reporting: this feature ensures real-time system connectivity.Target medical records are automatically captured, shared, and uploaded, with adherence to criteria and reporting guidelines set by pertinent authorities.
TA B L E 6