![]() We included clinical guidelines and primary peer-reviewed studies of any design, carried-out mainly in primary care (ie, family health care) patients aged 18 years and older, who were diagnosed with type 2 (non-insulin-dependent) diabetes mellitus, arterial hypertension, asthma, chronic heart failure, or osteoarthritis. Therefore, we aimed to identify and collect a set of evidence-based indicators that could be used for monitoring patients with chronic conditions at regular intervals in primary care using EMRs. On the other hand, there are deficits regarding the actual monitoring and structured follow-up. ![]() On one hand, there are currently no international standards for the monitoring of patients with chronic diseases by means of EMR in primary care. Surprisingly, there are no evidence-based specifications concerning the indicators that should be monitored at regular intervals. To efficiently monitor patients with chronic diseases, a well-structured and organized EMR system is crucial to ensure that all necessary information can be easily entered and retrieved, while no essential information is missed. Therefore, it is currently almost impossible to exchange data with digital applications that are increasingly available and used by patients. In a Swiss study, only up to 44.8% of the participating primary care physicians reported the usage of EMRs. In this global ranking of EMR usage, Switzerland ranked number 24. In 2012, 31 European countries were ranked based on the usage of electronic medical records (EMRs) in primary care. Too many clinical offices in Switzerland lack basic electronic devices since many general practitioners still use paper-based patient records. This model shows the existing variety of technically well-advanced applications as part of the monitoring process. The eHealth enhanced chronic care model was subsequently introduced as the means to improve the CCM in view of the progress and development of information and communication technology. The chronic care model (CCM) was originally introduced to graphically picture the concept of disease management. Moreover, the regular monitoring of chronic diseases poses huge challenges and requires knowledge and communication skills, as well as the capability of organization and coordination. The burden of these diseases consequently imposes a significant threat to health, quality of life, and economic status in the affected population. In particular, the prevalence of type 2 (non-insulin-dependent) diabetes mellitus, arterial hypertension, asthma, chronic heart failure, and musculoskeletal diseases is increasing rapidly around the world leading to increased multimorbidity and polypharmacy, especially in the older population. ![]() The majority of these diseases include cardiovascular diseases, chronic respiratory diseases, and diabetes. In 2016, the World Health Organization estimated that 71% of the overall deaths worldwide occurred due to noncommunicable diseases.
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