	100	<1	1	>1.0 risk is assigned
prevention		1-1.99	30	when there have been
		>2	100	one or more such
				episodes (as
				determined from dialogs)
Glucose	90	<1	1
control		1-2.99	20
		3-6.99	35
		7-10.99	80
		>11	200
Smoking	50	<0.1	0	<0.1 signifies that
cessation		0.1-0.99	10	patient is not a smoker.
		1-4.99	25	F = 0 is to make sure that
		5-9.99	40	the patient never receives
		>10	90	smoking cessation
				modules, as it is
				irrelevant.
Weight	45	<1	0.1	<1 means the patient
reduction,		1-2.99	10	is maintaining optimum
		3-9.99	30	weight, and any advice
		>10	60	would only be towards
				encouragingweight
				maintenance
Exercising
	30	<1	0.1
		1-5	4.0
		>5	8.0
Foot care	30	<1	0.1
		1-5	4.0
		>5	8.0
. . . more	. . .	. . .	. . .	. . .
contexts

The hypoglycemia prevention context is assigned a very high P value=100, and when R>2, the F value equals 100. Similarly in glucose control, when R=8, F equals 80.[0156]

In prioritizing at the time of content assignment,[0157]

content assignor

28 uses Z values which are numerically derived by multiplying R, P and F for each of the contexts. Dialogs corresponding to the context with the highest derived Z value are assigned to the patient at the start of each new session. However, in prioritizing content assignment for those contexts where R exists as a state (logical expression, text string or value), the above expression will not hold true. In this instance, the provider has the following options

Firstly, the healthcare provider may arbitrarily assign R values for each of the possible R states. For example, the R state ‘Feeling great’, to the query ‘How are u feeling today’ to a patient with depression may be assigned a low R value, since it represents a better prognosis in a patient with depression; and ‘Feeling terrible’ may be assigned a high R value.[0158]

Second, the healthcare provider may write the follow up into the actions itself. In this case, if the patient replies ‘Feeling terrible’, he/she is asked further queries that attempt to elicit the cause of his/her low mood. Alternatively the healthcare provider may create an action whereby the provider is immediately alerted to the fact of such a reply, so that it may be followed up by a telephone call, a personal visit, or the scheduling of an appointment.[0159]

Third, the healthcare provider may so program the protocols database such that when the R state for a particular context in a patient returns certain value, text string or logical expression, the protocols database automatically adds a specified dialog to the tasklist database for that individual.[0160]

Fourth, the healthcare provider may use the reporting interface and manually assign dialogs to those individuals whose profile database returns true for a specified R state, or a combination of R states.[0161]

Chart 2 (Z-value chart) shows the derived risk factors, and computed Z values for the same patient A at point of time=‘1 November 2001’[0162]

CHART 2


R value =	Corresponding
(From	F =	Z value =

Context, C	P value=	profile data)	(from Chart 1)	P * R *F

Hypoglycemia

	100	2.8	100	28000
prevention
Glucose	90	2.5	20	4500
control
Smoking
	50	2.2	25	2750
cessation context
Weight	45	2.1	10	945
reduction
Exercising
	30	4	4	480
Foot care	30	2.5	4	300

In patient A, the top priority (and the assigned content dialogs) would be towards preventing the possibility of a hypoglycemic episode (Z=28000). Next in priority would be to control the patient's blood glucose levels (Z=4500), and so on. At this point of time, automated content would primarily focus on the above two contexts, though ‘maintenance’ content would be assigned for the remaining contexts, namely smoking cessation, weight reduction and foot care. Further, regardless of the priority assigned to any context, when significant resistance is encountered (high W values), the automated content assignor provides only maintenance content for that context.[0163]

Over the next few weeks, the patient interacts with the system, and as a result, learns more about his/her condition, and is motivated to change some of his/her health related behaviors. It is also possible, especially in the case of diseases that run a more rapid course, that there has been progression of the condition in the meantime, which is independent of the medical management. As a result of the above the R values of the patient change in either direction for different contexts. At this point of time, the Z-value chart would read in the manner of[0164]chart 3 given below

CHART 3


R value =	Corresponding
(From	F =	Z value =

Context, C	P value=	profile data)	(from Chart 1)	P * R *F

Hypoglycemia

	100	0.9	1	90
prevention
Glucose	90	1.6	20	2880
control
Smoking
	50	1.5	25	1875
cessation context
Weight	45	1.5	10	675
reduction
Exercising
	30	3	4	360
Foot care	30	2.1	4	252

Here, the highest priority is given for (and consequently, maximal dialogs assigned would relate to) glucose control Z=2880. Following this, priority would be assigned to smoking cessation and weight reduction respectively. The reduction in the R value of hypoglycemia prevention context is likely the result of patient education about the symptoms of hypoglycemia and the techniques that are used to prevent hypoglycemia when self administering insulin. Z values that are at this level (z=90) may be safely managed by ‘maintenance dialogs’, which reinforce in the patient, at regular intervals, the need to avoid hypoglycemia. Similarly, if significant resistance were encountered to smoking cessation context meanwhile, then the system would revert to ‘maintenance dialogs’ in that context. In the above example, the Z values for glucose control have also reduced from 4500 to 2880, but this still represents an area of high priority, and at this juncture, a significant portion of the content would still relate to this context of health care. The R value for foot care has decreased from 2.5 to 2.1, but with a Z score of 252, this remains one aspect of the disease that would require the provider's attention.[0165]

For reasons of clarity, the above example illustrates the change in assigned content after the passage of a span of a few weeks. However, it must be understood that in the actual system, dynamic updating of the profile and content assignment would take place in real time, such that the system responds in real time to the changing profile of the individual patient. Maintenance dialogs are communicated with patients who are otherwise at low risk states for a particular context, in order to ensure the patient's sustained interest in the disease management process, as also to reinforce in the patient knowledge and correct attitudes regarding the disease context.[0166]

Measurements[0167]74D from monitoringdevice74 may be used, in addition to modify the computed R values by assigning ‘M’ values to ranges of values of74D. In the case of diabetes,monitoring device74 may be a glucometer, anddialog100 may be so programmed that when blood glucose levels are above a certain value, the old R value (R_GLC-OLD) gets multiplied by a certain factor M1 to yield a new R value (R_GLC-NEW). In the logical expression given below, M1 is the returned post dinner blood sugar value from monitoringdevice74 of patient A, in milligrams per deciliter (measurement74D).



	ACTIONS:

IF M₁ >500,

	THEN R_GLC-NEW=R_GLC-OLD * 3.5;
	THEN FOLLOWPREACUTE DIALOG 1001.

ELSE IF 300≦M₁≦500,

THEN R_GLC-NEW=R_GLC-OLD * 1.8;

THEN FOLLOW EDUCATIONAL DIALOG 16.

ELSE IF 200≦M₁≦300,

THEN R_GLC-NEW=R_GLC-OLD * 0.8;

THEN FOLLOWCONGRATULATORY DIALOG 22.

ELSE IF M₁<200,

THEN FOLLOW LOW PD-GLUCOSE DIALOG 11.

IF LOW PD-GLUCOSE DIALOG 11=POSITIVE,

	THEN R_HYPOGLY-NEW=R_HYPOGLY-OLD * 1.6

If the measured blood glucose values exceed 500 mg/dl, then the risk factor increases by a factor of 3.5 and[0168]

PREACUTE DIALOG

1001 is followed. If the measured blood glucose were to be between 300 and 500 mg/dl, then the risk factor would increase by 1.8 and an educational dialog would follow. However, if the returned values were in the normal range (200-300 mg/dl) a congratulatory statement would follow. If the values were on the lower range, a hypoglycemia prevention statement would follow. In this manner, it is possible to detect a developing complication and intervene early, in order to prevent the condition from worsening and presenting at a stage where it is more difficult and expensive to manage.

In addition, R values can be modified on the basis of the results of laboratory tests, data contained in medical records database[0169]62, medical claims database58 andadditional material database54. In the diabetes example, a lipid profile test done at the laboratory of the healthcare facility or elsewhere (additional material database). Similarly the failure of the patient to keep up an appointment athealthcare provider60 can also be used to increase the R value for a context.

Resistance Factor (W)[0170]

W, the resistance factor is particularly relevant in the management of chronic illnesses, where there is a tendency for patients to become non-compliant with medical regimens with the progression of time. While individualization and customization of the dialogs and management plans helps to prevent this to a great degree, it is also necessary to identify and quantify developing resistance at an early stage, and suitably modify the mode of management. W, the resistance factor quantifies the degree to which the patient is non-compliant with the treatment plan, whatever be the reason, in order that alternative approaches are explored.[0171]

Resistance in a particular context is inversely proportional to the motivation of the patient with regard to the particular context. Further, this motivation is amenable to change, as a result of information provided to the patient on the importance of that context in the entire health management process. So, when a patient is exhibiting high resistance in a context, the dialogs assigned to the patient take on the ‘maintenance mode’. ‘Maintenance dialogs’ differ from the ‘conventional dialogs’ in that these dialogs are[0172]

1. presented to the patient at a frequency that is less than other contexts with similar Z values,[0173]

2. intended to stimulate the patient's interest and curiosity, rather than stimulate the patient to change his/her health related behavior,[0174]

3. intended to convey information in a non-opinionated manner, and allow the patient to draw his/her own conclusions, and[0175]

4. atleast one reply to each query or teaching statement allows the patient to terminate the dialog relating to that context.[0176]

	CHART 4


	R	Corre-
	value =	sponding
	From	F values

profile

(from

Z value =

Context, C	P value=	data	Chart 1)	P * R * F	W value

Hypoglycemia

	100	0.9	1	90	2.6
prevention
Glucose	90	1.6	20	2880	2.5
control
Smoking
	50	1.5	25	1875	25.1
cessation
context
Weight	45	1.5	10	675	0.5
reduction
Exercising
	30	3	4	360	0.5
Foot	30	2.1	4	252	1.0
care

The W values for smoking cessation are quite high (25.1) in this patient. So the patient is put on maintenance dialogs for this context till the issue is resolved by a patient-provider personal interaction, or the W values show a decreasing trend as a result of the maintenance dialogs. A pro-active stance of attempting to achieve total smoking cessation is deferred until then, for the abovementioned reasons. If it is determined, as a result of the patient-provider interaction(s), that the patient will actively work towards achieving complete cessation, the W values and/or R and L values may be ‘reset’ to default levels by the provider, by accessing profile database directly, or by the use of a custom action at[0178]

dialogs

100.

As is evident from Chart 4, resistance values are independent of R, P, and F values. This is because the method for the derivation of W values is different from the method of derivation of the remaining values. R depicts the risk status of the individual within a context, while W has more to do with the level to which the patient is motivated (or resistant) to the context under question.[0179]

Consider another example: Patient H is on follow-up for coronary arterial disease (clogging of the blood vessels, the cause of heart attacks). Patient H is also a chronic smoker, and it is well known fact that quitting smoking remains the single best intervention in this patient that will reduce the patient's risk of developing heart attacks and strokes in the future. So the[0180]

content assignor

28 would commence intensive efforts to achieve smoking cessation in this individual, by the use of education modules. Hopefully, this will cause the individual to quit smoking. However, a subset of patients may be put-off by these messages, and consider them intrusive to their lifestyle, which may lead to an increased dropout rates and non-compliance with the remainder of medical management provided by the system. In these patients, smoking cessation still remains a long-term goal but it is recognized that conventional dialogs may prove to be counter-productive. Instead, maintenance dialogs such as the one depicted below, are communicated to the patient.

[MAINTENANCE DIALOG IN A RESISTANT SMOKER]

[0181]1. A RECENTLY CONCLUDED STUDY CONFIRMS THE FACT THAT SMOKERS ARE TWICE AS MORE LIKELY TO DEVELOP IMPOTENCE DUE TO VASCULAR CAUSES THAN NON-SMOKERS.

A. OK [ACTION: GO TO NEXT DIALOG][0182]

B. MORE [ACTION: W[0183]_SMOKER-NEW=W_SMOKER-OLD* 0.8;]

[ACTION: GO TO DIALOG ‘SMOKER-IMPOTENCE-101’][0184]

C. SKIP [ACTION: W[0185]_SMOKER-NEW=W_SMOKER-OLD* 1.5]

[ACTION: GO TO NEXT DIALOG][0186]

The patient is informed about the harmful effects of smoking, more as a teaching statement or a news headline, than as an attempt to induce him/her to quit smoking. The idea here is to provide information, and stimulate the patient's interest, and to arouse the patient's curiosity. Responses to statement include ‘Ok’, ‘More’ and ‘Skip’. If the patient chooses ‘Ok’, the next dialog within the program is served to the patient. If the patient chooses ‘More’, it means that the patient is curious about this aspect. So, in addition to providing the patient more details of the study, the value of resistance in the context of smoking cessation is reduced by a multiplying it with 0.8. On the contrary, if the patient decides to ‘Skip’ the statement, the value of resistance is increased.[0187]

When resistance increases above a certain operator-determined value, it is obvious that the problem is unlikely to be solved by remote dialogs alone, and alternative approaches are explored, including bringing up the topic at a personal interaction, such as an interview, or a telephone conversation.[0188]

After any dialog is presented to the patient, a marker is placed in the profile of the patient regarding the same, in order that the content assignor does not automatically present the same dialog to the patient more than once. However, the same dialog may be presented to the patient at the discretion of the provider.[0189]

Methods to Avoid the Development of Resistance—[0190]

Dynamic dialog paradigm—In this paradigm, possible replies to query include ‘Skip Query’. When this option is chosen by the patient, the program at remote terminal[0191]72 proceeds to the next query, and a marker indicating the particular reply is added toprofile database44. Additionally, a task may also be added to thetasklist database46. This task can include serving the dialogs to the patient at a later date and in an alternative format.

When implemented, dynamic dialog paradigm allows the patient to dodge a query. This is because; some queries can be very personal or embarrassing to patients. Further, not all patients are forthcoming when initially queried regarding such topics as domestic abuse, usage of psychotropic substances, etc. In diseases such as mood disorders, it is not uncommon for patients to abuse psychotropic substances in a misguided attempt to ‘treat’ their condition. Though the topic may be better discussed with the patient at a personal interview, it is advantageous to screen patients using the remote monitoring system, to identify those patients in whom this aspect needs to be further elucidated.[0192]

By allowing the patient to ‘dodge’ a query, the healthcare provider identifies those individuals who have reasons not to reply to the query. In the instance that a patient ‘Skips’ a query, this aspect is either explored at a future personal visit, or by a dedicated dialog for eliciting responses from this subset of patients.[0193]

If this option were not available to the individual, it is likely that a considerable proportion of patients would simply deny the condition, thus making the data unreliable. Thus, dynamic dialog paradigm has the net effect of increasing the reliability and veracity of the data entered into the system and available to the healthcare provider.[0194]

Online dialog dynamism—In order to sustain the patient's interest and continued attention in health management and educational materials, it is necessary that the content adapts itself to the attention span and interest of the patient. It is further necessary that patients progress through the program at their own pace, and that the content matches evolving patient status or the evolving understanding of the patient condition. Since the patient's perception of the health benefits to be derived from the system tend to vary with time, it is important that the focus of interaction be dictated by the user wherever possible and that the dialog is responsive to the individual in real time (Online dialog dynamism) For example, on a particular day, individual[0195]70 might not be keen on completing his/her educational module, while on another day, a topic in the module might stimulate the individual's interest, and he/she may wish to learn more about it.

Online dialog dynamism allows patient's replies to change the presented content in real time without the invoking of[0196]

communication system

50. Replies to a teaching statement can include ‘Ok, ‘More’ and ‘Skip’. If the user selects ‘Ok’, the teaching statement proceeds along the originally intended course. However, if ‘More’ is chosen by the patient, additional latent teaching statements from content130 are invoked. On the contrary, if ‘Skip’ is chosen, the teaching statements are terminated, and are invoked at a later date. ‘Skip’ invoked within online dialog dynamism will not normally modify the resistance factors, though it is possible to program it to do so.

Customization—At the time of registration of the patient into the system, the patient is queried regarding the preferred[0197]

remote terminal

72 andmonitoring device74 with which the patient is to communicate with the system. Other preferences include whether the patient prefers audio, videos and other multimedia components (including video games) as a part of the content (wherever supported by the remote terminal and communication network50). Another point where customization may be implemented is in the frequency, timing and total amount of dialogs served to the patient, as a part of the interaction.

Additionally, customization may be in relation to the scheme and mode of presentation of content on the display screen of[0198]

remote terminal

72. In the preferred embodiment, the customization components are stored inprofile database44 in theprofile computer20. In an alternative embodiment, these components are stored inremote terminal72 and/ormonitoring device74, and script programs received fromprofile computer20 are automatically customized at the level of the terminal72, anddevice74, and then presented to the patient.

Customization is aimed at making the system more user-friendly and capable of optimally utilizing the data transfer capabilities of[0199]

communication network

50, and the display and processing capabilities ofremote terminal72 andmonitoring device74. In one embodiment, the patient provides the details of his/her devices and communication network. For example patient may be asked to choose among a list of supported devices and type of content. In an alternative embodiment, theprofile computer20 detects the type ofremote terminal72,monitoring device74 andcommunication network50, and optimizes the content for delivery. For example patients who are connected by a low-speed 36 kbps modem would have lesser amount of multimedia content served to them than those patients in whom communication is established by high speed internet. Specific techniques of implementing this are well known in the art.

A few examples of specific instances where customization of the dialogs to the[0200]

remote terminal

72,monitoring device74 andcommunication network50 is particularly advantageous are given below.



PDA (Personal Digital Assistants)-

Integration of	Patients may be reminded to take medications on time,
script programs with the	in the form of alerts.
daily task planner	Appointments with the healthcare provider may be
program within the	automatically scheduled on the basis of entries in the planner.
PDA.
Serial recording	Graphical representations of the parameters, e.g. blood
of parameters measured	glucose levels may be created at the level of the terminal 72
bydevice 74.	itself, with regular updating of the profile computer. The
	patient may communicate with the system less often, with the
	one-time transmission of stored data in the intervening period.
Symptom diary	A patient with depression, epilepsy, asthma, etc may
maintenance	create entries, and even store measurements 74D in a
	symptom diary program that stores the data within the
	terminal 72. At regular intervals, or when the local processing
	algorithm determines that the patient is at increased risk,
	he/she is advised to contact the healthcare provider
	immediately. In the case of asthma, the additional advantage
	is that the daily activities of the patient may be correlated with
	the PEFR (Peak Expiratory Flow Rate) values of the patient,
	which is an objective measure of the severity of disease, in
	order to find what factors actually are responsible for the
	exacerbation of the patient's condition.
	Additionally, subjective-objective studies may be
	performed whereby, for example, the PEFR is compared with
	the patient's subjectively reported symptoms.

Digital TV-

Enhanced rich	There are no limits as to the bandwidth of transmitted
multimedia content	content within Digital TV, and rich multimedia and audio
suited to the patient's	containing data streams may be transmitted.
disease state.	Patients who need to exercise are shown provided
	daily videos of weight reducing exercises to help them in their
	workouts. This may be scheduled at the patient's convenience.
	Patients may be shown videos of former smokers
	recounting their personal experiences with smoking cessation,
	as a psychological support mechanism to encourage them to
	try and quit smoking. Support may extend into the critical
	quitting phase, especially where the patient is experiencing
	withdrawal symptoms.

PC (and also PDAs) connected to High-speed internet-

Speech	Instead of receiving written queries, a computer
generation and voice	generated face reads out the queries. Replies are received by
recognition programs	deciphering the voice of the patient, so that no text input is
	required by the patient. The same applies also to the
	maintaining an electronic symptom diary.

Monitoring device 74 directly connected to communication network 50-

Automatic	Bathroom scales (device 74) of patients with
measurements of	congestive heart failure are connected throughterminal 72 or
physiological parameters	directly toprofile computer 20. An increasing weight over a
with direct	few days or weeks is used to activate a script program in the
communication to	terminal 72, either directly or after going throughprofile
profile computer
20.	computer 20.
	A similar method is adopted in the case of diabetes,
	whereby an unusually high blood sugar level is used to
	activate a script program interminal 72.
	In the case of asthmatics, a low PEFR is used to
	activate the script program interminal 72.

Though specific instances are displayed for specific[0201]

remote terminals

72, with the increasing convergence of technology, it may be possible in the near future for some remote terminals to perform the functions that have been described with otherremote terminal72. Further, the specific instances listed above are for illustrative purposes only, and are not meant to limit the scope of the invention. Many other variations of the above may be generated and transmitted to patients in alternative embodiments.

Serial Follow Up of R, L and W Values, and Its Implications in Patient Management:[0202]

Since the R values are measured in arbitrary units, serial follow up of the values in a patient provides far more information than that provided by a single value. Different combinations of the trend in R, L and W values with respect to time identifier ‘T’ suggest a variety of possibilities, and this may be used in patient management. This is illustrated by[0203]factor combinations 1 through 5 below:

1	Isolated	More	More	Patient's	Follow-up dialog to
	high risk result or	or less constant	or less constant	health status is	determine the cause of this
	rapidly			worsening. Patient	sudden deterioration in health
	deteriorating risk			may be ‘pre-acute’.	status. To rule out fallacious
	factors in one or				results. Alert provider to the
	more contexts.				case, who may establish contact
					with the patient by phone or
					personally.
2	Slow	More or	More or	Probably	Confirm
	deterioration in R	less constant	less constant	disease progression	whether disease is really
	factors in a			that is irrespective	progressing, by the use of
	previously well			of the management.	diagnostic tests and measuring
	patient				disease related parameters, and
					at personal visits to healthcare
					facility. Manage accordingly.
3	Patient	More	Increasing	Patient	Reduce the content on
	is gradually	or less constant		probably feels that	those contexts where the patient
	deteriorating with			the system is not	is showing resistance. Likewise,
	regard to R			helping him/her	increase the content on those
	factors (R value			much since he/she is	contexts where the patient has
	is increasing).			doing quite well on	requested more information at
				the health related	any time. Provide ‘maintenance
				parameters anyhow.	content’, that teaches the patient
				There is a high	the importance of continued
				likelihood of losing	follow up and compliance, even
				this patient to	if otherwise asymptomatic, or
				follow-up.	feeling well.
4	Any	Decreasing	High	Information	This aspect would
	value	or low	for that context.	about this context is	need to be explored at a personal
		reliability in a		not reliable when	interview, and after the patient's
		single context		obtained remotely	confidence has been secured.
				by the system.	This context may, in fact hold
					the key to the diagnosis, and the
					patient's condition may never be
					cured completely without
					resolving this.
5	Any	Decreasing	Any	Information	Obtain
	value	or low reliability	value.	obtained from the	information from other sources
		spread over		patient is inherently	such as the patient's friends,
		multiple		unreliable.	relatives, and employers/co-
		contexts.			workers. Consider the possibility
					of malingering. In psychiatric
					patients, rule out underlying
					psychosis.

Factors Combination 1:[0204]

Progressively deteriorating (increasing) R values over multiple contexts in a patient over a short period of time, with more or less constant reliability and resistance suggests that the patient's health status is deteriorating. The patient may be in the process of developing an urgent ‘pre-acute’ condition, which, if left untreated may rapidly progress into full blown disease. The first step would be to confirm the fact of the existence of the pre-acute condition, and this is followed by the actual management process. In some cases, however, the confirmation step may be skipped and one may directly go to the step of intervening urgently. Approaches for urgent intervention in the patient may include a personal visit to the patient's home, fixing up an appointment at the healthcare facility, a telephone call to the patient and/or his/her loved ones, and the usage of dialogs that enable the more intensive monitoring of the patient, atleast until the patient is considered out of risk. The advantage of earlier detection and intervention in the patient's condition is that interventions done at this time are more efficacious, less expensive, and demand fewer resources on the healthcare system—in terms of time and personnel.[0205]

Earlier detection of ‘pre-acute’ conditions for the purpose of intervention is implemented by the use of standardized questionnaires and dialogs that look for the presence of ‘sentinel signs and symptoms’ that represent the earliest warning signs of deteriorating patient's health. In the case of diabetes, include an isolated abnormally high blood glucose measurement (diabetic hyperosmolar coma) or an episode of sweating accompanied by palpitations and drowsiness (hypoglycemic attack).[0206]

Logical expression below depicts the[0207]

PREACUTE DIALOG

1001 that is assigned when there is an isolated blood sugar test result of greater than 500 mg/dl (precursor of diabetic hyperosmolar coma)

PREACUTE DIALOG 1001 [M[0208]₁>500]

QUERIES:[0209]

[0210]1. DID YOU FORGET TO TAKE ONE OR MORE DOSES OF YOUR MEDICATION?

A. YES [ACTION: SERVE DIALOG ‘COMPLIANCE 21’][0211]

B. NO [ACTION: GO TO NEXT QUERY][0212]

[0213]2. DID YOU HAVE AN UNUSUALLY LARGE MEAL?

A. YES [ACTION: SERVE DIALOG ‘COMPLIANCE[0214]23’]

B. NO [ACTION: GO TO NEXT QUERY][0215]

[0216]3. DO YOU HAVE ANY OF THE BELOW: FEVER/ FEELING UNWELL/ NAUSEA?

A. FEVER [ACTION: SERVE DIALOG ‘ACTIVE INFECTION 91’][0217]

B. FEELING UNWELL [ACTION: SERVE DIALOG ‘MALAISE 92’][0218]

C. NAUSEA [ACTION: SERVE DIALOG ‘ACTIVE INFECTION 92’][0219]

D. NONE OF THE ABOVE [ACTION: GO TO NEXT QUERY][0220]

[0221]4. PLEASE REPEAT A BLOOD GLUCOSE SAMPLE {REPEAT M1}

A. REPEAT M[0222]₁>500 [ACTION: GO TO NEXT QUERY]

B. REPEAT M[0223]₁<500 [ACTION: ADD INFO TO ‘ERROR.LOG’]

[0224]5. YOUR BLOOD SUGAR LEVELS ARE DANGEROUSLY HIGH!!! IF LEFT UNCHECKED YOU MAY DEVELOP SERIOUS COMPLICATIONS. PLEASE SELF ADMINISTER 8 UNITS OF INSULIN AND CHECK YOUR BLOOD SUGAR LEVELS 8 HOURLY.

A. OK [ACTION: FOLLOW DIALOGS ‘INTENSE MONITOR 67’;][0225]

[ACTION: ADD TASK ‘CHECK BLOOD SUGAR 11’8 HRLY][0226]

[ACTION: ALERT PROVIDER IMMEDIATELY][0227]

Since this high a blood glucose value places the patient at a particularly high risk for developing complications and has important implications for further management, it is necessary to know the exact circumstances under which the patient's blood glucose has reached these levels. This is done by asking the patient to reply to[0228]

PREACUTE DIALOG

1001.Pre-acute dialog1001 contains queries that attempt to rule out less worrisome causes of the high glucose levels. For instance, if the patient has forgotten to take his/her regular dose, then he/she is advised to take it immediately, and obtain a repeat blood glucose value after 2-3 hours. Likewise, if the patient has had an unusually large meal that particular evening, he/she is advised to add a little extra insulin to the usual nightly dose. Alternatively, if the patient reports that he/she has been running a fever or has been feeling unwell for a few days, an urgent visit to the healthcare facility is necessitated, since this level of blood glucose may be the earliest sign of developing diabetic hyperosmolar coma, a potentially serious condition where, in the presence of active infection, the blood glucose control mechanisms are seriously compromised, and which may rapidly progress to uncontrollable systemic infection, coma and death.

Further, if a repeat blood glucose test returns as normal, and it is determined that the high initial levels were a result of a technical fault in measuring device[0229]74 (ERROR), then the information is stored in the ERROR.LOG file, and no further action needs to be taken, other than recalibrating or replacingmonitoring device74.

In the management of depression, a sentinel sign can include the patient's daily rating of his/her mood on a scale from one (‘feeling low’, depressed) to ten (‘feeling great’, happy). Other sentinel symptoms include the patient's sleep patterns, appetite, feeling of tiredness and activity, etc. The progressively worsening of the patient's risk factors on these contexts over a short span of time, such as a few days is picked up by the monitoring application, which in turn, may send dialogs to explore the reasons for the patient's worsening mood, or fix an appointment with the patient, or alert the healthcare provider depending on the preset protocol as determined by the provider. The provider may additionally initiate a phone call to the patient, or make a personal visit to the patient, or assign additional exploratory dialogs with the patient (Was there some recent setback at the workplace/at home, to dear ones/in relationships? Is the patient regularly taking his/her medications? Have suicidal thoughts ever intruded (suicidal ideation) into the patient's consciousness? etc)[0230]

For obvious reasons the patient may be advised to report to the facility immediately if he/she reports suicidal ideation. In addition to receiving alerts regarding the worsening mood status of the patient, the patients' non-response to dialog programs would constitute sufficient reason to alert the provider. This is especially more so when accompanied by a recent decreasing mood level in the patient (increasing R values).[0231]

device

74.

Factors Combination 2:[0233]

It is a well known fact in medicine that, while the treatment of chronic diseases improves the quality of life and increases longevity, the underlying pathological process remains unaltered, and often worsens with time. This necessitates an increase in the dosage of administered drugs, or the consideration of alternative modes of therapy. Further, the therapeutic effects of drugs and management tend to decrease on long term usage. For instance, diabetes patients develop the phenomenon of insulin resistance, whereby the body requires an increased dosage of insulin to control the blood sugar level to the same extent as earlier. Patients on oral hypoglycemic agents may require a switchover to injected insulin. Similarly, patients with HIV infection on anti-retroviral therapy would exhibit lowering CD4 counts, as a result of developing resistance of the virus to drugs.[0234]

Common to the above processes is the fact that the increasing risk factors takes place over a span of months, or even years. In these patients, there is a gradual deterioration of risk status (increasing value of R), especially the values that are derived as a result of objectively measured physiological parameters, and scored questionnaires. So, when this is seen in a previously well patient with more or less unchanged or improving L and W status, this indicates primary progression of disease. To confirm the above, the healthcare provider may additionally prescribe diagnostic laboratory tests, such as tests for anti-insulin antibodies in the case of diabetes, and Viral Load tests in the instance of HIV infection.[0235]

Factors Combination 3:[0236]

Notwithstanding the mechanisms to increase the patient's compliance with medical regimens such as dynamic dialog paradigm, online dialog dynamism and customization, in a small subset of patients, resistance (W) to the system may show a gradual increase with time. This may be accompanied by a simultaneous increase in risk factors (deteriorating patient's health status). In patients with low pre-existing risk factors (well-motivated patients), this may be because the patient feels that he/she has not much to gain from the system, since his/her health status and management is low risk anyhow. On the contrary, some patients may be intrinsically less motivated, or less inclined to look after their health and may show high risk factors with high resistance.[0237]

Regardless of their present health status, both patient-groups are still at risk of deteriorating. Patients who exhibit this phenomenon will show gradually increasing resistance (W) values over multiple contexts, with or without accompanying deteriorating R values. Reliability values may also be adversely impacted. Continuing to remotely manage these patients without taking into account the developing resistance will have a negative impact on the effectiveness of treatment regimens and continuation rates for these patients.[0238]

Managing these patients would require that the patient is kept on ‘maintenance content’, content that is primarily educational in nature, and emphasizes upon the importance of continued follow up and compliance with medical advice, even if the patient is otherwise asymptomatic. Further, the patient is taught that many diseases remain under the surface and progressively hurt the body, and emerge after a ‘latent period’ even if they do not cause symptoms meanwhile. Further, there are as few as necessary dialogs initiated which pertain to the contexts where resistance is encountered.[0239]

However, some of these issues are likely to be better resolved at personal interviews and the monitoring application is crucial in that it serves to detect early and alert the provider to this happening, in order that a personal interaction is initiated.[0240]

Factors Combination 4:[0241]

Every effort is made to query patients on sensitive topics in a non-opinionated fashion and in an open ended manner (by allowing the patient to elaborate). However some patients may still feel uncomfortable about answering queries that relate to sensitive topics. Some of these queries are relevant to the health condition, and can have a significant impact on the management, e.g. a history of psychotropic drug abuse in a psychiatric patient, a history of alcoholism in a depressed patient. Often these queries hold the key to the diagnosis and the patient's condition may never be treated wholly without resolving the particular issue. In addition, some queries, while not directly related to the patient's condition, if returned positive, can have a significant impact on management, e.g. a 70 year old lady on follow up for congestive heart failure is queried about possible elder abuse. The query however is needed to rule out one of the commonest causes of poor health in these patients, and is in the best interests of the patient.[0242]

As has been described earlier, patients are allowed the option of skipping the query, so that the provider is alerted to the fact that the patient has reasons whatsoever to ‘dodge’ the query. The reasons can range from the queries' being embarrassing to the patient (e.g. the screening for elder abuse query) to the patient's being uncomfortable with that particular aspect of his/her own life (e.g. alcoholism and drug abuse in a depressed patient) may simply wish to skip it.[0243]

High resistance implies that the patient has reasons not to answer the query, whatever the reason. When there is high resistance in a single or a few isolated contexts, with or without low reliability for these contexts, the information regarding this context within profile database would need to be elaborated by the provider. This aspect could be explored at a personal interview and after the patient's confidence has been secured. Alternatively this is done through the usage of dialogs that are more sensitive in their language, and of dialogs which look for indirect pointers towards the condition of interest. Alternatively, ‘pointer queries’ are used which query the patient on topics that are commonly associated with the health condition of interest.[0244]

For example, consider patient D on follow up for depression who gives a history of occasional alcohol intake. However, he says that he has no more than a couple of drinks a week, and denies that he has ever consumed alcohol as a result of his feeling ‘low’. Ruling out alcoholism (different from ‘social drinking’ and moderate alcohol consumption) is very important in this patient, since his depression may in fact be a result of chronic intake of alcohol. It is a well known fact that alcoholics tend to downplay the actual level of their intake, so the patient's denying a history of alcoholism would not be of much value in the decision making process.[0245]

Instead the system attempts to assign risk scores for alcoholism by looking for indirect markers within medical claims database[0246]58, medical records database62 andadditional material54. These include a history of frequently presenting in the emergency room with cuts and wounds (acquired as a result of the drunken state), frequent lung infections (from aspiration of stomach contents), a history of being in a de-addiction program, the physician notes of prior consultations, results of old/recent laboratory tests that are associated with a high alcohol intake (a fatty liver, and cirrhotic changes seen on a CT scan done for some other reason, a raised blood Gamma-glutamyl-transferase enzyme levels), etc.

Further, the patient may be administered adaptations of standardized screening tests for alcoholism, such as the CAGE Test, either at a same sitting, or spread out over many sittings. If the screening tests and/or any of the indirect markers test as suspicious for alcoholism, this aspect is explored further through the use of dedicated dialogs or at personal communications with the patient.[0247]

In addition, patients who are former alcoholics, and who are on follow up for some other condition may be monitored for a recurrence of uncontrolled drinking in the same manner as detailed above. In this case, these patients may be monitored and provided supportive management in order to prevent the alcohol recurrence status.[0248]

Factors Combination 5:[0249]

When the information obtained from the patient over multiple contexts has a low reliability, or the reliability factors are decreasing, this indicates that the information obtained from the patient is inherently unreliable. Healthcare management in these patients cannot be done on the basis of patient provided inputs alone, since the patient provided data is seen to be unreliable (inconsistent with known data) and possibly fallacious.[0250]

Malingering is the condition where a healthy person simulates symptoms of disease for personal gain. Malingerers often present to medical providers as difficult to diagnose, a typical cases. While this gives the provider an initial clue to the real cause of the patient's symptoms, it is seldom possible to make a sure diagnosis of malingering on this basis, in an individual patient. Further, some malingerers do not simulate new symptoms but simply exaggerate the severity of the disease state for the sake of gain, which may be financial compensation from a former employer, or an insurer; not having to go to work and sympathy from dear ones. Malingering is responsible for a significant portion of wasteful healthcare expenditure, and detecting this is a priority in any healthcare system.[0251]

An important characteristic of malingering is a frequent change in the patient's ‘story’ and inconsistency between the history and the severity of symptoms. It is often difficult for the provider to keep track of every single detail of the patient-provider interaction in order to seek inconsistencies in the history. Even if this were to be done, an attempt to visualize the data in the context of malingering would not prove to be worthwhile in view of the time, effort and cost expended.[0252]

This however may be done through the use of the system in the following manner: when the reliability is low for one or more contexts and there is an inconsistency in the risk factor scores obtained from different sources, the suspicion of malingering is raised. This is because malingerers do not report groups of symptoms in the manner that they usually present to a provider. This is different from Factors Combination 4 in that the unreliability is spread over multiple contexts, and that these contexts do not necessarily deal with ‘sensitive topics’, or those topics where an ordinary person would be uncomfortable in relating to a provider.[0253]

Further, these patients are likely to exhibit high resistance, and this is spread over multiple contexts. This is because these patients have a constant underlying fear of being ‘caught’ and so try to avoid supplying additional data as much as possible. So, they are far more likely to choose ‘Skip’, when compared with a patient who is genuinely suffering from the condition.[0254]

The mechanism may be further refined such that within a dialog, there are no more than one or two queries of interest, which are interspersed within general queries pertaining to ‘neutral’ topics, i.e. those topics which are likely to put the individual off-guard with regard to the true significance of the query.[0255]

Factors Combination (Miscellaneous):[0256]

If a new intervention is planned for a specific condition, and is in relation to a particular context, such as a novel drug for the control of blood glucose, it would be possible to choose those patients who are having greatest difficulty in controlling their blood sugar levels based on their computed R values. This group of patients would likely represent the diverse background of patients with diabetes, with regard to other parameters. If a randomized study comparing the efficacy of the two treatments is planned, then the control group (patients who are not treated at all, or those who are placed on standard treatment) can consist of patients with comparable R values. The R values of patients following the new treatment can be followed to see the response of the glycemic control to the new drug. In this manner, R values may be applied in the context of conducting research studies, and clinical trials in the evaluation of new drugs, etc.[0257]

Improving R values that relate to the symptoms and quality of life factors, after the institution of a new drug would suggest that the new drug is more effective in controlling this given set of symptoms in the patient, and is more likely to be accepted in this patient.[0258]

A final advantage of the system is that there is huge research benefit in identifying parameters that can correlate to subgroups of patients who respond differently to treatment. All data relevant to the patient's health condition, including the patient's replies to specific queries are stored in the profile database, each in a separate column. Additional columns describe the response of the patient to specific medical interventions (in the form of the change in the R values as a function of time, i.e. pre-treatment and post-treatment values of R)[0259]

Chart 5 depicts an example profile database for a group of 10 patients on treatment for depression, who additionally consume alcohol. Some of the patients being followed up agree to cease consuming alcohol consumption completely, and are given support and motivation to do so, while the remainder patients are placed on the regular follow up schedule for depression. For the sake of clarity, only three contexts (1, 2 and 3) are shown in the chart. Cumulative L and W values for the patient are shown. However, in the actual study, the R, L and W values of more contexts, and more patients would be taken into account.[0260]

	CHART 5


	R, P, F VALUES OF SPECIFIED CONTEXT

PATIENT	ALCOHOL	R₁	R₂	R₃	L_ALL	W_ALL	R₁	R₂	R₃	L_ALL	W_ALL

#1	YES	3.5	1.6	2.5	6.1	0.7	1.6	1.2	2.4	10.1	10.4
#2	NO	1.6	5.1	1.9	2.8	0.9	1.5	5.5	1.7	2.5	0.9
#3	YES	11.5	5.3	4.1	9.1	1.4	6.1	2.1	2.8	10.1	1.2
#4	NO	1.2	1.4	1.7	12.1	0.4	1.1	1.2	1.5	12.2	0.4
#5	NO	10.6	6.2	3.8	14.1	1.7	8.1	4.2	3.4	11.2	1.8
#6	NO	5.5	4.0	2.2	8.1	5.4	3.9	6.1	2.6	8.2	4.3
#7	NO	3.4	1.3	2.8	7.5	0.9	2.8	1.2	2.6	7.4	0.7
#8	YES	1.0	1.2	1.1	9.8	0.6	1.0	1.3	1.2	9.6	0.5
#9	YES	5.4	4.1	2.1	0.4	1.7	3.7	6.4	2.3	0.6	1.6
#10	NO	10.6	6.2	3.8	14.1	1.7	8.1	4.2	3.4	11.2	1.8

A researcher wishes to know whether depressed patients who successfully cease alcohol consumption have a better prognosis than those who don't. In order to find out, he/she searches the entire profile database of patients on follow for depression to select patients for inclusion into one of two groups—test and control group. The test group consists of individuals who have completed the alcohol cessation program, while the control group consists of those who have not opted to cease alcohol consumption. The researcher now matches patients in the groups such that there is a patient with similar R, L and W factors in the test group for every patient with similar factors in the control group. Matching for factors is done for those contexts that are known to have a bearing on the long term prognosis of the depression, including the age-group, sex of the patient, the dosage of the drugs administered to the patient and most important, the initial risk state of the patient's depression. Of course, matching is not done for the context of alcohol cessation (Context ‘CEASE ALCOHOL’ in the chart), since this is what the researcher is interested in studying.[0261]

Matching is preferably done by the use of automated algorithms that match patients who exhibit similar values for the risk factors that are to be matched. The matching algorithm also excludes the patients whose data has[0262]

1. low reliability, since a study done on unreliable data is bound to decrease the quality of the study[0263]

2. high resistance, since such patients are unlikely to adopt or continue the new management in any case. Management in these patients is directed towards decreasing the resistance first, and then attempt behavior modification.[0264]

3. very low risk factors of interest—the change in the values of R in the context of interest is likely to be so low, that the likelihood of errors is greatly increased in this case.[0265]

Chart 6 shows an algorithm for the automated assignment of patients to the two groups. Individuals whose risk factors and values meet allocation criteria as decided by the researcher are automatically assigned into the groups as shown below.[0266]

CHART6

TEST GROUP[0267]

IF CEASE ALCOHOL=‘YES’[0268]

THEN PATIENT =‘TO TEST GROUP’[0274]

CONTROL GROUP[0275]

ELSE IF CEASE ALCOHOL=‘NO’[0276]

THEN PATIENT=‘TO CONTROL GROUP’[0282]

EXCLUDED GROUP-REASON LOW L VALUES[0283]

ELSE IF L[0284]_ALL<4.0

THEN PATIENT=‘EXCLUDED GROUP REASON: LOW L VALUES’[0285]

EXCLUDED GROUP-REASON HIGH W VALUES[0286]

ELSE IF W[0287]_ALL>3.0

THEN PATIENT=‘EXCLUDED GROUP REASON: HIGH W VALUES’[0288]

EXCLUDED GROUP-REASON LOW R VALUES[0289]

ELSE IF R[0290]₁<2.5

OR R[0291]₂<2.0

OR R[0292]₃<1.5

THEN PATIENT=‘EXCLUDED GROUP REASON: LOW R VALUES’[0293]

It is obvious that there may be more than one reason to exclude a patient from the study. On the basis of the exclusion criteria, patients are assigned to the groups as shown in Chart 7 below.[0294]

CHART 7


INCLUDED PATIENTS

TEST	CONTROL	EXCLUDED PATIENTS
GROUP	GROUP	REASON

#
1	#7	LOW L VALUES #9
#8	#2	HIGH W VALUES #6
#3	#5	LOW R VALUES #4, #8

Once this is done, the researcher has two groups of patients who are comparable in all respects, except that one group has ceased alcohol consumption at that point of time, while the other group continues to consume alcohol. Now, the researcher analyzes the difference between the present R factors of the two groups. In addition, it is also necessary to verify that none of the patients enrolled in the study have developed an unacceptably high resistance or low reliability during the course of the study.[0295]

Standard statistical methods are used to test the level of significance of the R factors as a result of the alcohol cessation. R factors of more than one context, which are scored on the basis of replies, may be used to measure the improvement in the risk status of the patient. Alternatively, the R values are derived from standard questionnaires that score the risk status of the patient objectively e.g. SF12, SF36, Minnesota Living with Heart Failure Questionnaire, Geriatric Depression Scale. Alternatively, laboratory tests may be used to evaluate the effectiveness of the management e.g. in the case of blood glucose control, Serum Hb[0296]_AICvalues, that give an indication on the long term (80-100 days) level of blood sugar control may be used. If there is a statistically significant benefit (which may not be attributed to chance alone) from these analyses, it is concluded that alcohol cessation in depressed patients is helpful in the treatment of their depression. In this manner a researcher is able to prove or refute earlier hypotheses.

The advantage in using the system for the purpose of research is that the method of storage of data in the form of R, L and W values is ideally suited to risk assessment. In case of doubt, since all inputted replies to queries would additionally be archived by the system, it is possible to validate the assigned R, L and W values. Further, since the data for patients over multiple healthcare facilities is stored in the same database format, it is possible to integrate the results over multiple healthcare facilities. This makes it convenient to conduct large multi-centre studies, and further validates the results of the study.[0297]

In addition, the cost of conducting the study is greatly reduced, since the data is already preformatted for the purpose of comparison. It is of importance to note that any context can be studied in relation to any other context over a large group of patients. It is also possible to conduct studies comparing the effectiveness of different healthcare facilities management protocols by a similar method. Further, it is possible to randomly assign patients to one of two groups (prospective randomized controlled trials), each receiving different treatments and comparing the effects of the different treatments. This information may be further added into the new protocols for better automated content assignment. So this method may also be used in the evaluation of different protocols of management in the system, and be used to refine the protocols assignment process in any group of patients.[0298]

Process Governing Dynamics:[0299]

In view of the above, it is apparent that the provider utilizes a combination of automatically selected and manually assigned content to elicit further information from the monitored individuals. Automated content utilizes a combination of the level of risk of the patient, the immediacy/urgency of delivering the content to the individual, the individual's reliability and resistance, and the individual's profile variables such as comprehension capacity, motivational drivers, etc. Automatically assigned content is queued in the tasklist database, for communication with the individual at the next connection. However, the provider may also assign content manually from the report generator interface, and has the additional option of modifying, appending and deleting content from the tasklist database.[0300]

The monitoring application regularly scans the individual's entire profile and seeks variables, and combinations of variables within the profile, for which there are defined protocols within the protocols database. Protocols are program statements that instruct the monitoring application to perform[0301]

actions

140 when a given set of conditions are fulfilled.Actions140 include alerting the healthcare provider to the presence of a combination of variables that may signify an impending ‘pre-acute’ state in the patient. The protocol shown below is for patients with mood disorders. A gradually worsening mood over many days is often the first sign of an incoming depression in these patients. Since these patients are at risk for committing suicide in their depressed state, it is important that their mood fluctuations be continuously monitored, and that these individuals are prevented from deliberately harming themselves.

PROTOCOL[0302]

(1) IF PATIENT REPLY RECEIVED=‘FALSE’[0303]

AND MOOD[0304]_RECENT=‘FEELING TERRIBLE’

THEN ACTION: ALERT PROVIDER, ‘PATIENT NOT RESPONDING’[0305]

(2) ELSEIF MOOD[0306]_CURRENT=‘FEELING TERRIBLE’

AND MOOD[0307]_CURRENT-1=‘FEELING FINE’

AND/OR MOOD[0308]_CURRENT-2=‘FEELING FINE’

THEN ACTION: FOLLOW WORSENING_MOOD DIALOG[0309]

(3) ELSEIF MOOD[0310]_CURRENT=‘FEELING TERRIBLE’

AND MOOD[0311]_CURRENT-1=‘FEELING TERRIBLE’

AND MOOD[0312]_CURRENT-2=‘FEELING TERRIBLE’

THEN ACTION: FOLLOW PERSISTENT DYSPHORIA DIALOG[0313]

(4) ELSEIF MOOD[0314]_CURRENT=‘FEELING FINE’

AND MOOD[0315]_CURRENT-1=‘FEELING GREAT’

AND MOOD[0316]_RECENT=‘FEELING GREAT’

THEN ACTION: FOLLOW MOOD_SURVEILLANCE PROTOCOL[0317]

In the first condition in the protocol, the monitoring application is activated when replies to queries are not received in time by the system. Given that the patient has recently stated that he/she has been feeling terrible, the lack of reply is likely to suggest a worsening mood level in the patient, since patients who are very depressed are unable to sum up enough energy to even perform the activities of daily existence. The action here is to alert the provider, so that he/she may initiate personal contact with the patient, since dialogs are unlikely to be of any benefit (the patient has ceased responding to the remote apparatus)[0318]

The second condition of the protocol, if returned true, implies that the patient's mood has been worsening. This may be because of external factors, such as problems with family, and at the workplace, or may be without any apparent reason. The reason for the worsening mood is explored using the WORSENING_MOOD dialog. If it is determined that the patient's mood is worsening without any apparent reason, then such a patient is kept on close follow up. Alternatively, the provider may schedule a priority appointment with the patient.[0319]

The third condition of the protocol, if returned true, implies that the patient has been steadily feeling terrible. This may be because of the patient's failure to take medication or due to a recent event, or even due to the failure of the medication to act in the particular patient. The reason for the patient's persistently low mood is elucidated by the PERSISTENT_DYSPHORIA dialog.[0320]

In the fourth condition, the patient's mood has been deteriorating, though it is still at the level of ‘feeling fine’. This patient would require more intensive monitoring for worsening mood, and the monitoring application switches the patient to the MOOD-SURVEILLLANCE_PROTOCOL, whereby there is more frequent communication between the patient and the system, and the threshold for alerting the provider to a worsening mood is lowered.[0321]

While the preferred embodiment of the invention has been illustrated and described, as noted above, many changes can be made without departing from the spirit and scope of the invention. Accordingly, the scope of the invention is not limited by the disclosure of the preferred embodiment.[0322]

FACTOR COMBINATIONS

RISK FACTORS,

RELIABILITY,

RESISTANCE,

MANAGEMENT

IMPLICATION