Mobile services to empower patient with heart failures

Scenario context: 

Coordination of care for a patient who will be cared for and supported in the health community. The Care Manager is the ‘coordinator’ of the 'Heart Failure Management Plan' and ‘Medical Anticipatory Care Plan’. These plans were defined by the Healthcare professionals and accepted by the patient. The care manager will oversee the plan and ensure that the different ‘Actors’ involved are communicated with and that care is followed up at the premises of the patient or at the acute or care ward. 

Care coordinator
Healtcare Practitioner
Care network
HIE and healthcare systems for hospital, GPs, …
Send/retrieve patient data (save/update data)
Send Alert/alarm
Send/retrieve reports
Send reminders
Send/retrieve care plan (save/update the care plan)
Technical Process Flow: 
  1. After agreement between the cardiologist and the patient, the cardiologist updates the care plan with the status agreed
  2. Report is sent to the HP
  3. The cardiologist notifies the care coordinator
  4. Appointment are scheduled with the patient for the visits
  5. The patient collects his measurements( weight, blood pressure and heart rate) periodically on devices
  6. The patient accesses to the information about heart disease and manage his life consequently
  7. If alert/alarm occurred, a notification is sent to the care coordinator
  8. The care coordinator takes the right actions after reviewing the information that were collected

The care plan is reviewed and updated periodically by the cardiologist with all relevant actors


Possible issues: 

XDR enables sending a “push” alert to another party. This may be realised with XDR (which is a web service-based solution), or, within an XDS affinity domain, with either DSUB or NAV.