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APPENDIX L: HISTORY OF RAMP-DM AND JADE

The defining key feature of the RAMP-DM care is the risk stratification feature made possible
by the Joint Asia Diabetes Evaluation (JADE) study. One of the defining points of diabetes
care in Hong Kong dates back to 1995 when the Hong Kong Data Register (HKDR) was
formulated. Through the eventual linkage of the data-rich registry to the territory-wide
electronic medical records, the JADE programme was established in 2007 and later adapted
in 2009 to form the now well-established RAMP-DM care in publicly funded primary care
clinics.

More specifically, the JADE programme features a comprehensive risk engine, while the
basis of the web-based JADE portal incorporates HKDR-derived data from patients receiving
secondary or tertiary care and risk algorithms. The insights gathered from the HKDR enabled
the current risk stratification of patients in the RAMP programme based on risk factor
combination and complications. Moreover, in-built risk equation also integrates patient’s
clinical data to predict five-year disease trajectory of major events across CHD, stroke, end-
stage renal disease and all-cause mortality (Fung et al., 2012; Wan et al., 2018).

In reviewing the historical context of the development of diabetes care in Hong Kong, two
studies have aptly captured the evolution of the varying data-driven diabetes care models
(Chan et al., 2019; Ng et al., 2018). The latest study by Chan and colleagues (2019) provides
an overview and highlights the importance of data-driven care to unveil insight into clinical
outcomes, identify unmet needs of patients and most importantly evaluate the effectiveness
of different intervention strategies for diabetes care in Hong Kong. In a similar study by Ng
and colleagues (2018), evidence in support of benefits of the multi-components that
formulate diabetes management care in Hong Kong were discussed.

Reference to a multi-disciplinary team-based integrated approach coupled with information
technology and patient empowerment programmes were key to improving diabetes care in
Hong Kong. As a mechanism to bolster patient empowerment and treatment adherence, the
issuance of a personalised report for patients has led to improved patient
and health professional communication. The resultant goal was to encourage
patients to optimise treatment targets through lifestyle and medication modification. In
moving forward, the study called for strengthening financing Schemes through PPP as a
potential option with establishment of community-based integrated care centres as a feasible
and cost-effective solution for Hong Kong.

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