Coordinated Care & Cure Delivery Platform

Management of Personalised Care Plans

C3DP equips the multi-disciplinary care team members with a tool to create personalised care plans for patients suffering from multiple chronic diseases.

 

High level functions

  • Reviewing patient medical summary via integration with local care sites
  • Care Plan creation, and editing with user friendly graphical interfaces
  • Supporting HL7 Care Plan Domain Analysis Model
  • Integration with several clinical decision support services for risk prediction and stratification, recommendation reconciliation, poly-pharmacy management and personalised goal and activity suggestions
  • Tracking patient activities and measurements via integration with Patient Empowerment Platform
  • Collecting feedback and questionnaires from patients via integration with Patient Empowerment Platform
  • Calendar for plan activities
  • Messaging among multi-disciplinary care team
  • Notifications between care team members about care plan activities
  • Messaging among care professionals and patients via integration with Patient Empowerment Platform

Medical Summary View: Patient conditions, medications and observations, with weight chart

Patient Date View: Observations and questionnaires that the patient has recorded via the Patient Empowerment Platform

Key Features 

Personalised goal and activity suggestions for the care plan of the patient based on Evidence based guidelines: The system is integrated with tens of Clinical Decision Support (CDS) services for risk prediction and stratification, recommendation reconciliation, poly-pharmacy management and personalised goal and activity suggestions. These CDS services have been implemented based on evidence-based clinical guidelines for four major chronic diseases: diabetes, chronic kidney disease, heart failure and depression. Integration via the CDS services is enabled via the CDS Hooks API and any CDS Hooks compliant CDS service can be plugged in easily.

Care plan and patient data models based on global knowledge: C3DP is fully compliant with tens of HL7 FHIR® clinical resources (e.g. CarePlan, Goal, MedicationRequest, Appointment, Condition, Observation, Communication, Questionnaire, AuditEvent) for both care plan and patient record data models. It benefits from the high-performing and scalable HL7 FHIR® Repository onFHIR.io as the data repository and all the interactions between the Web-based frontend and the backend takes place via the HL7 FHIR® RESTful API.

Seamless integration with local care sites: C3DP supports HL7 FHIR® RESTful API to synchronize the latest medical context of the patient with local EHR systems. Integration with local health care systems that do not inherently support HL7 FHIR® is achieved via C3-Cloud Interoperability Middleware.

Reinforce active patient involvement in care planning: C3DP is integrated with the Patient Empowerment Platform ensuring patient needs are respected in decision making and reinforce treatment adherence.

Secure handling of patient data: C3DP already supports single sign-on mechanisms to be seamlessly integrated with local care sites’ user authentication systems. It supports role-based authorization, secure storage of patient data and audit logging to ensure accountability. Widely preferred standards and specifications like OAuth 2.0, OpenID Connect 1.0, HL7 FHIR® SMART App Launch Framework, and IHE Audit Trail and Node Authentication (ATNA) profile are supported.

Care Plan Editing: Personalised goal suggestions

Care Plan Viewing: Goals for the patient

Care Plan Viewing: Activities in the patient’s care plan

Care Plan Editing: Personalised goal suggestions