Pathway-Driven Coordinated Telehealth System for Management of Patients With Single or Multiple Chronic Diseases in China: System Development and Retrospective Study.

Our system has potential to provide effective management support for single or multiple chronic conditions simultaneously. The tailored closed-loop care pathway was feasible and effective under the "three-manager" mode in China. One direction for future work is to introduce advanced artificial intelligence techniques to construct a more personalized care pathway.