Through proactive dispensary dynamic monitoring, Moscow medical teams will be able to track the health of about one million residents who have serious chronic conditions, all through online oversight. This initiative was announced by Anastasia Rakova, the Deputy Mayor for Social Development, highlighting a bold step toward leveraging digital tools to manage ongoing care for the city’s population.
A new segment has been added to the electronic medical record called “My Self-Regulatory Questionnaire.” In this area, patients can securely enter up-to-date information about their health status, symptoms, and daily experiences with their conditions. The data flows to treating clinicians, enabling a clearer picture of a patient’s trajectory over time and allowing for timely actions when needed.
Clinicians will monitor these trends remotely and, if necessary, will invite patients to unscheduled appointments to coordinate additional testing or modify therapy plans. The system is designed to catch subtle changes early, so interventions can be made before complications arise, reducing hospital visits and improving outcomes.
Rakova noted that the proactive dispensary dynamic monitoring program began operating across all adult city outpatient clinics at the start of the year. The rollout marks a shift toward continuous monitoring rather than episodic care, aligning with broader goals of preventive health and patient empowerment through digital tools.
“A dedicated self-control questionnaire was integrated into the electronic medical records with a user-friendly automatic reminder feature. Physician assistants will guide patients on how to use this service, ensuring broad access and comprehension,” the deputy mayor explained. “Moreover, personalized questionnaires tailored to each patient’s specific dispensary condition are used, and automated alerts are issued to doctors when a patient shows deviations in their self-monitoring results, such as a rise in blood pressure.”
The information entered by patients serves multiple purposes: it helps clinicians assess how well current treatments are working, supports adjustments to therapy regimens, and signals when additional diagnostic studies may be warranted. This data-driven approach aims to optimize treatment effectiveness and minimize unnecessary interventions, all while maintaining patient comfort and convenience.
Patients can complete the self-control questionnaire within its dedicated section or continue from the “My Health Diary” area. The questionnaire items are organized according to the patient’s particular disease profile, ensuring relevance and precision. Smart notifications prompt timely data entry, reinforcing regular self-monitoring as a routine part of care rather than a one-off task.
In support of this initiative, 400 paramedics work directly with residents to promote active involvement in health management. They help people understand medical advice, adhere to prescribed regimens, and coordinate appointments and tests. If needed, the workforce will be expanded to 600 specialists to maintain service levels and ensure broad access across the city.
Analyses of mortality causes at home informed the prioritization of conditions for dispensary observation. The program targets a spectrum of common and high-risk diseases, reflecting the needs of the local population. Included among the priority nosologies are type II diabetes mellitus, high cholesterol, arterial hypertension, coronary heart disease and myocardial infarction, atrial fibrillation and flutter, chronic heart failure, acute cerebrovascular events, chronic obstructive pulmonary disease, and peptic ulcer disease. This comprehensive scope ensures patients with chronic illnesses receive proactive, continuous attention rather than periodic, reactive care.