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| Shared cloud portal |
| Define a shared collaborative workspace, with secure access from actual health care team members and the patient/close relatives, based on regulations for privacy and security. |
| Implement cross-organisational access from the patient’s electronic health record to all the involved systems (hospital, local doctor/GP, municipality home care services, and national health portals with relevant information and functions). |
| A customised workspace and user interface on all relevant platforms, also for mobile solutions. |
| Automatic back-end synchronizing of stored information to the relevant EHR systems (at the hospital, local doctor/GP, municipality home care services) for necessary medical documentation and activity log documentations. |
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| Information flow functionalities |
| Integrated information flow, where all team members involved have immediate access to relevant real-time information and current patient status. |
| Real-time information of health care action plans and status of tasks, with two-way e-communication between team members and the patient. |
| Constant visualization in a dashboard of defined risk factors, risk stratification, and the progress. |
| Health care actions and support with visual indication of fulfilment and improvements according to a plan. |
| Automatic trigger of unexpected events or unnormal deviations according to a plan, based on triage algorithms. |
| Integration of electronic prescriptions to keep control of active medications, also integrated with a patient’s medicine dispenser with programmed time intervals to monitor medication taken and with relevant warnings. |
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| Patient involvement and support |
| Registration of «what I want my carers to know about me?» and «what matters to me?» |
| Integration of telemedicine functions with the patient’s self-monitoring and recording of vital sign parameters with regular report on status based on disease-specific questionnaires and patient-reported outcomes reports. |
| Integration with implanted devices and sensors such as pacemakers and ICD systems that regularly report cardiac situations and arrhythmia events. Blood glucose sensors that monitor and regulate insulin therapy. |
| Integration with medical equipment used by the patient such as PAP/CPAP/sleep apnea assistance technology, home respiration equipment, and home dialysing equipment. |
| Implemented e-consultation functionalities with video solutions in order to facilitate virtual contacts and remote medical consultations. |
| Implement virtual rehabilitation plans and activities for the patient to self-manage and carry out defined activities for training and re-establish functions for active daily living. |
| Electronic messages and support for the patient in a user-friendly workspace with easy access to all relevant information and personal activity tasks. |
| Integration of mobile self-help and well-being third-party applications. |
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| Teamwork support |
| Teamwork functionality with easy involvement of new team members for the particular patient depending on the actual situation and competence needed. |
| Task handling function, where a dedicated task can be assigned to a specific person for follow-up within a deadline, and a visual overview for all team members on the ongoing tasks with status. |
| The patient’s own daily tasks and recordings of activity and medical measurements are automatically included in a visual dashboard showing the degree of self-management and improvements according to a plan. |
| Integration of telecare alarm systems and response centre services for necessary actions and follow-up on critical alarms and warnings. |
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