Personalised Care Plan Management Platform
The Personalised Care Plan Management Platform (PCPMP) enables all members of the multidisciplinary care team to manage and coordinate patient-centered, integrated care plans, based on each patient’s baseline and most recent clinical data, following clinical evidence.
This involves, amongst others:
Create personalised care plans with an easy-to-navigate flow
Be notified when to update the care plan to each patient’s changing needs
Receive evidence-based recommendations
Have a comprehensive overview of all relevant up-to-date information, regardless of the source of the data (hospital, health care center or municipal health care)
Communicate with patients and coordinate care with other members of the care team
The PCPMP is supported by a Clinical Decision Support System.
Overview of the functionalities
Review medical summary
The healthcare team can review the patient’s medical summary as retrieved from the local electronic health records: conditions, medications, immunizations, allergies, lab results, vital signs, risk scores, procedures, encounters.
The user can also inspect quantified observations such as vital signs in the form of charts.
Below you will find screenshots of the most important functionalities.
Care plan management
An easy-to-navigate flow guides the healthcare professional to create a care plan for the specific conditions of patient.
The healthcare professional will receive reminders about the important parameters that will affect the personalized decisions about goals and activities.
Intelligent tools suggest recommended treatments for the healthcare professional to decide on.
Review / edit care plan summary
The healthcare professional can edit the details when needed, and add goals and activities from scratch: patient orders, medication (via ATC codes), diet recommendations, lab requests, appointments, referrals, questionnaires (PROM/Symptom reporting).
Review care plan progress
Some activities may have related observations like meal photos, lab results or vital sign measurements.
When there are associated data provided by the patient himself via the Patient Empowerment Platform (e.g. blood glucose measurement) or by a clinical system (e.g., HbA1c result), these results are automatically matched and the latest record.
Review patient-provided data
Review patient-provided data as retrieved from the Patient Empowerment Platform: Vital sign measurements such as blood pressure, weight (as customizable dashboards), care plan feedback, PROMs filled in, symptoms reported via questionnaires, messages sent to the care team.
The healthcare team can also inspect quantified observations such as vital signs in the form of charts.
Messaging
The healthcare professional can send messages to patients, care team members or other practitioners to share information.
