Care is organized in evidence-based coordinated care pathways based on the patient’s current disease state (i.e., active versus remission) and medication regimen. Based on guidelines, relevant literature, and consensus statements, ten pathways were developed; five 6-week scenarios for patients with active diseases (Fig. 11.2a), and five annual scenarios for patients in remission (Fig. 11.2b). Each pathway has a predefined number of clinic visits, electronic visits (e-Care), and lab sets (Table 11.1). Whenever the physician switches the scenario on using the provider interface, a care pathway is automatically generated (Fig. 11.2c). The pathways can be modified according to the physician’s discretion. Standard operating procedures (SOPs) are included in the pathway, as well as a reference cost model (Fig. 11.2d; [32]).

Outcome measurements are collected routinely and include assessment of level of disease control, quality of life, and productivity at work, school, or home. During clinic visits, validated questionnaires are used for collection of patients’ outcomes data. For disease control the Harvey–Bradshaw Index [33] is collected for Crohn’s disease (CD) and the partial Mayo score [34] for ulcerative colitis (UC). For quality of life assessment, patients fill out the short IBD questionnaire [35] (sIBDQ), and for work productivity assessment the work productivity and impairment questionnaire [36] (WPAI). For monitoring of disease control at home—which enables care providers both to detect relapses as well as to measure outcomes—short four-question questionnaires consisting of just patient reported outcomes (PROs) were developed: the mHealth index (mHI) for UC (mHI-UC) and CD (mHI-CD) [37]. These questionnaires were specifically developed to be implemented in a mobile application (Fig. 11.3). To monitor costs, a charge-model was implemented which shows real-time changes in encountered charges whenever procedures are added or removed from the pathway.

We aimed to include the five relevant aspects of telemedicine in our IT system as well. (1) To enhance communication a messaging functionality was included in the platform. Patients can send messages to their care coordinator 24 h/day, and will receive a response within 24 h on business days. In the initial version only patient–provider communication was included. To further enhance communication and support effective care coordination, a provider–provider messaging system was developed as well. (2) The developed mHIs are used for home monitoring and automated messages are sent to the care coordinators whenever the score indicates disease activity. (3) For educational purposes an IBD specific educational program was developed. This program includes five educational modules covering different aspects of IBD diagnosis, treatment, and management. Every module ends with a test question. Furthermore, a glossary was included in this section of the app, which enables patients to look up specific topics of interest. (4) For enhancement of general wellness in IBD patients six 6-week wellness programs were developed tailored towards IBD: fitness, yoga, meditation, diet, and acupressure modules were developed, as well as a 6-week e-behavioral antinational therapy (eBAT) program for patients suffering from anxiety and depression. Lastly, (5) all data is accessible in a de-identified fromat for research purposes. This enables us to identify patterns in the collected data and improve care over time.

Recently, first outcomes of this program were presented and preliminary results show encouraging data. UCLA IBD patients were compared to a matched control group using insurance claims data from a major California insurer. Significantly, less corticosteroid use was observed in the UCLA IBD group (12  vs. 31 %, p  = 0.03) and numerically more methotrexate (1  vs. 6 %, not significant (NS)) and adalimumab (15  vs. 21 %, NS) use. Furthermore, patients in the UCLA IBD group had 1.3–3.4 times more frequent biomarker testing (p < 0.001), and 89 % fewer hospitalizations and 75 % fewer ED visits (NS) [38].