SmartCare D3.1 Pilot Level Service Specification - … · The SmartCare project is co-funded by the...

The SmartCare project is co-funded by the European Commission within the ICT Policy Support Programme

of the Competitiveness and Innovation Framework Programme (CIP) .

Grant agreement no.: 325158

Pilot Level Service Specification

Deliverable 3.1

WP3 - Integration Infrastructure Architecture and Service Specification

Pilot level Service Specification (D3.1)

Public of 65 31 October 2013

Document information

Organisation responsible

IFIC

Author(s)

Leo Lewis (IFIC)

Bridget Moorman (CHA)

Contributing partners

Pilot sites

Veli Stroetmann (empirica)

Eleftheria Vellidou (Vidavo)

Delivery date

4th November 2013

Dissemination level

P Public X

Version history

Version Date Changes made By

0.1 22nd October 2013 Initial draft Leo Lewis, Bridget Moorman

0.2 25th October 2013 Update with Empirica edits Bridget Moorman

0.3 3rd November 2013 Update Veli Stroetmann

Eleftheria Vellidou

Bridget Moorman

Leo Lewis

1.0 4th November 2013 Final draft Leo Lewis

Statement of originality

This deliverable contains original unpublished work except where clearly indicated otherwise.

Acknowledgement of previously published material and of the work of others has been made

through appropriate citation, quotation or both.



Table of Contents

1 Introduction 6

1.1 Purpose of this document 6

1.2 List of acronyms used in the document 6

2 Defining the SmartCare System 7

2.1 SmartCare Use Cases and Pathways 7

2.2 ICT Systems for SmartCare Pathway Workflows 7

2.2.1 Care Pathway Workflows and Functions 7

2.2.2 Care Pathway Information Recording Systems 9

2.3 SmartCare Users and User Rights 13

2.4 SmartCare Functional Blocks 14

3 Defining Pilot Level ICT Functional Specification 18

3.1 Aragon 18

3.1.1 Aragon – Long-Term Home Care Support 18

3.1.2 Aragon – Discharge Pathway 22

3.2 Southern Denmark 27

3.2.1 Southern Denmark – Long-Term Home Care Support 27

3.2.2 Southern Denmark – Discharge Pathway 32

3.3 Scotland 38

3.3.1 Scotland – Long-Term Home Care Support 38

3.3.2 Scotland – Discharge Pathway 43

3.4 Friuli Venezzia Giulia 47

3.4.1 Friuli Venezzia Giulia – Long-Term Home Care Support 47

3.4.2 Friuli Venezzia Giulia – Discharge Pathway 51

4 Towards SmartCare Architecture: Technical Mapping 55

4.1 Outputs from Functional Blocks 55



4.2 Standards, Standards Guidelines or Profiles Containing Standards that

can be used for SmartCare System 58

4.3 Architecture Considerations for SmartCare Functional Blocks 61

5 Summary, Conclusions and Next Steps 65



List of figures

Figure 1: Generic pathway for integrated long-term home care support (ICP-LTCare) 8

Figure 2: Generic pathway for integrated home support after hospital discharge (ICP-Discharge) 8

Figure 3 - Information Recording Systems for ICP-LTCare Pathway 9

Figure 4 - Information Recording Systems for ICP-Discharge Pathway 10

Figure 5 – Possible ICT Infrastructure Components for ICP-LTCare 11

Figure 6 - Possible ICT Infrastructure Components for ICP-Discharge 11

Figure 7 - Information Sharing Mechanisms for ICP-LTCare 12

Figure 8 - Information Sharing Mechanisms for ICP-Discharge 13

Figure 9 - Simplified Functional Diagram for SmartCare 14

Figure 10: ICP-LTCare: Current ICT Infrastructure & Systems - Aragon 18

Figure 11: ICP-LTCare: SmartCare ICT Infrastructure & Systems - Aragon 19

Figure 12: ICP-Discharge: Current ICT Infrastructure & Systems - Aragon 22

Figure 13: ICP-Discharge: SmartCare ICT Infrastructure & Systems - Aragon 23

Figure 14: ICP-LTCare: Current ICT Infrastructure & Systems – Southern Denmark 27

Figure 15: ICP-LTCare: SmartCare ICT Infrastructure & Systems – Southern Denmark 28

Figure 16: ICP-Discharge: Current ICT Infrastructure & Systems – Southern Denmark 32

Figure 17: ICP-Discharge: SmartCare ICT Infrastructure & Systems – Southern Denmark 33

Figure 18: ICP-LTCare: Current ICT Infrastructure & Systems – Scotland 38

Figure 19: ICP-LTCare: SmartCare ICT Infrastructure & Systems – Scotland 39

Figure 20: ICP-Discharge: SmartCare ICT Infrastructure & Systems – Scotland 43

Figure 21: ICP-Discharge: SmartCare ICT Infrastructure & Systems – Scotland 44

Figure 22: ICP-LTCare: Current ICT Infrastructure & Systems –Friuli Venezzia Giulia 47

Figure 23: ICP-LTCare: SmartCare ICT Infrastructure & Systems –Friuli Venezzia Giulia 48

Figure 24: ICP-Discharge: Current ICT Infrastructure & Systems –Friuli Venezzia Giulia 51

Figure 25: ICP-Discharge: SmartCare ICT Infrastructure & Systems –Friuli Venezzia Giulia 51

Figure 26: Continua E2E architecture 60



1 Introduction

1.1 Purpose of this document

The document fulfils the requirements of WP3 first deliverable, D3.1, Pilot level ServiceSpecification for SmartCare. This service specification outlines the two main use casesdriving SmartCare and then identifies the different functions and activities within the usecases and affiliated information, communication and technical requirements. There is anascending level of technological solutions required based on the legacy capabilitiesavailable at each of the pilot sites. It is hoped that this document can function in somecapacity as an addendum to a procurement document where necessary as well as serve asa road map for different European regions at different levels of infrastructure to be able toimplement SmartCare from a services perspective.

The ongoing work presented in this document is part of the following tasks:

T3.1 Initial starting point in legacy technology

T3.2 Initial SmartCare integration infrastructure architecture

T3.3 Home linked services (V.1) specification

1.2 List of acronyms used in the document

Acronym Translation

CR Care Recipient

DSL Digital Subscriber Line

EHR Electronic Health Record

EPR Electronic Patient Record

GP General Practitioner

HCP Health Care Provider

HL7 Health Level 7

HSCP Health and Social Care Provider

HSSP Healthcare Service Specification Project

ICP Integrated Care Pathway

ICT Information and Communication Technologies

I/FC Informal/Formal Carer

IS Information System

LTC Long Term Care

SCP Social Care Provider

SMS Short Message Service

SOA Service Oriented Architecture

TSCP Third Sector Care Provider

VPN Virtual Private Network



2 Defining the SmartCare System

SmartCare’s main mission is to implement and validate information, communication and technology

(ICT) based support for integrated healthcare, social care and self-care (informal care), for

different health/living conditions along integrated care pathways for improved health and wellness.

This integrated care is to occur mainly in the home of the care recipient. Many stakeholders are to

be served by the integrated service model: healthcare providers, social care providers, informal

care providers, third party voluntary care providers and the care recipients/patients. Each of the

stakeholders has a different perspective and needs access to services and information at different

levels. It is hoped that an integrated platform and service model will allow for appropriate access

by each stakeholder as well as provide an integrated view of the patient/users’ needs in the clinical

and social realms.

2.1 SmartCare Use Cases and Pathways

SmartCare is focusing on two use cases: integrated home support after a hospital discharge (ICP-

Discharge) and integrated long-term home care support (ICP-LTCare). Each of these use cases has

quite a few similar functional requirements, however, the entrance and exit from the workflow

path are different. Moreover, they are related in that an exit point from ICP-Discharge can be an

entry into ICP-LTCare. In the Figures 1 and 2 are the care pathways for each of the use cases.

2.2 ICT Systems for SmartCare Pathway Workflows

2.2.1 Care Pathway Workflows and Functions

In ICP-LTCare (Figure 1), the entry point can be either a referral from a healthcare provider or a

referral by a social care provider, or following an ICP-Discharge. This triggers an assessment for the

patient home care needs and enrolment into SmartCare with an initial integrated home care plan

developed. The patient is discharged from the hospital with a coordination of the integrated care

delivery and/or revision to the initial integrated home care plan.

When the patient is at home, there are four pathway steps for integrated care: on-site provision of

formal health care, on-site provision of formal social care, on-site provision of informal care and

remote provision of health/social care to the home (telemonitoring, telecare).

After or concurrently while the care is administered in one or more of the pathways, that care is

documented in the integrated system. The control and reassessment of the home care recipient is

done by reviewing the documented care.

After the control/reassessment point, the home care recipient may be temporarily admitted to an

institution (i.e. hospital or day-care centre) and re-entry into the coordination of the integrated

care delivery and/or revision to the home care plan.



Figure 1: Generic pathway for integrated long-term home care support (ICP-LTCare)

Overall coordination of integrated care delivery / care planning

Entry point:Referral bysocial careprovider

Assessmentof needs forhome care

Enrolment toSmartCare

pilot service(ICP-LTCare)

Initialintegratedhome care

plan

Coordinatedcare delivery/ revision ofinitial home

care plan

On-siteprovision offormal social

care

On-site(at home)

provision offormal

health care

On-siteprovision of

informal care

Remoteprovision of

health /social care:telemoni-

toring,telecare

Integrateddocumenta-

tion ofprovided

home care &self-care

Temporaladmission toinstitution(hospital,day carecentre)

Control /reassessmentof needs forhome care

Exit point:Disenrollment

fromSmartCare

pilot service(ICP-LTCare)

Entry point:Referral byhealth care

provider

In ICP-Discharge (Figure 2), the entry point is a pending patient discharge. The functional flow is

the same as for ICP-LTCare except at the control/reassessment point the home care recipient will

either be readmitted to the hospital, disenrolled from the ICP-Discharge or transitioned to the ICP-

LTCare.

Figure 2: Generic pathway for integrated home support after hospital discharge (ICP-Discharge)

Overall coordination of integrated care delivery / care planning

Entry point:Discharge

from hospitalimpending

Assessmentof patient’s

needs forhome care

Enrolment toSmartCare

pilotdischarge

service (ICP-Discharge)

Initialintegratedhome care

plan

Dischargefrom hospital

Coordinatedcare delivery/ revision ofinitial home

care plan

On-siteprovision offormal social

care

On-site(at home)

provision offormal

health care

On-siteprovision of

informalcare

Remoteprovision of

health /social care:telemoni-

toring,telecare

Integrateddocumenta-

tion ofhome careprovided

Readmissionto hospital

(if required)

Control /reassessmentof needs forhome care

Exit point:Transition into

SmartCarelong-termcare pilotservice

Exit point:Disenrollment

fromSmartCare

pilot dischargeservice



2.2.2 Care Pathway Information Recording Systems

The following information generation/recording systems will be used/interfaced in the SmartCare

system (please also see Figure 3 and 4):

Hospital Health Care Record System: generates the admission, readmission anddischarge summaries, the health home care plan; accepts information from theSmartCare system into patient health care record; prepares and documents patientconsent for participation in SmartCare System

Community Health and Social Care System: generates health and social care plan,documents health social care provided along with review and assessment of careprovided, provides health and social care discharge summary for pilot exit and/oradmission to the hospital

General Practitioners (GP) systems: prepares and documents consent for participation inSmartCare system; receives discharge summary information from Hospital Health CareRecord System; generates and/or receives hospital re-admission information for homecare recipient; generates and/or receives SmartCare discharge and/or referral (for ICP-LTCare) information for home care recipient

Caseload management and appointment systems: generates interventions and servicesfor formal health, social and informal care workers for care delivered in home; this maybe separate systems providing a similar function by the different SmartCare users

Telehealth and telecare systems: measures vital parameters prescribed by homehealthcare plan; measures environmental and social parameters prescribed by homesocial care plan; provides automated alerting of critical situations to health or socialauthorities; provides virtual access to formal health, social care and informal careproviders for home care recipient

Care Recipient held record: information care recipient documents regarding the carethey receive

Figure 3 - Information Recording Systems for ICP-LTCare Pathway

Integrated Long-Term Home Care Support

Information Recording Systems for ICP-LTCare

Care Co-ordinationCommunity

H&SC record –paper/ER

Interventions &Services info

Caseloadmanagement &appointment

systemsCare Recipient

held record




held record




held record

Self Care infoTelehealth &

telecaresystems

ReferralinformationCommunity

Health record– paper/ER, GP

system

ReferralinformationCommunitySocial Care

record –paper/ER, GP

system

Assessmentinfo

CommunityH&SC record –

ER, paper

ConsentCommunity

H&SC record –ER, paper,SmartCare

database, GPsystem

Integrated CarePlan

CommunityH&SC record –paper/ER, GP

system

CombinedInterventions &

Services infoCommunity

H&SC record –paper/ER,

service userself care plan

Review & Re-assessment

infoCommunity


Admission infoCommunity H&SC

record –paper/ER,

Hospital PAS,residential & day

care record,GP system

Discharge infoCommunity

H&SC record –ER, paper,SmartCaredatabase,GP system



Figure 4 - Information Recording Systems for ICP-Discharge Pathway

Integrated Home Support after Hospital Discharge

Information Recording Systems for ICP-Discharge

Admission andimpending

Discharge dateinfo

Hospital PAS

Assessmentinfo

Hospital record– paper/ER

ConsentHospital

PAS/record –paper/ER,SmartCaredatabase,GP system

Care PlanHospital record

– paper/ER,community

H&SC record -paper/ER

Care Co-ordinationCommunity


Discharge infoHospital &Communityrecords –

paper/ER, GPsystem




held record




held record




held record

Self Care infoTelehealth &

telecaresystems


Services infoCommunity


Review & Re-assessment

infoCommunity


Re-admissioninfo

CommunityH&SC record –

paper/ER,Hospital PAS,

GP system

Discharge infoCommunity

H&SC record –paper/ER,SmartCaredatabase,GP system

Discharge &Referral info

Community H&SCrecord –

paper/ER,SmartCare

database, GPsystem

Figure 5 and 6 depict the possible information and communication technology infrastructure

components that could be allocated amongst the pathway functions to provide communication of

the integrated care information along the workflow. Due to the various legacy installations at the

pilot sites, the infrastructure elements listed range from the use of paper based systems to

broadband telecommunications access.



Figure 5 – Possible ICT Infrastructure Components for ICP-LTCare


Possible ICT Infrastructure Components for ICP-LTCare

Communityhealth

LAN/WiFi/2/3/4GBroadband,Paper Filing

System, GP LAN CommunityLAN/WiFi/2/3/4G

Broadband,Paper Filing

systemCommunitysocial care


System

CommunityH&SC


System

CommunityH&SC


system, GP LAN

CommunityH&SC


system, GP LAN

CommunityH&SC

LAN/WiFi/SPA,Call Centre,Paper Filing

system

CommunityLAN/WiFi/2/3/4G

Broadband,Paper Diarysystem, Care

Recipient homebroadband,

Paper record


Broadband,Paper Diary

system, CareRecipient home

Broadband,Paper record



system, CareRecipient home


SPA/Call CentreLAN/WiFi



system

HospitalLAN/WiFi &

Community H&SCLAN/WiFi/

GP LAN/PaperFiling system/Residential &Nursing home

LAN/WiFi

CommunityH&SC LAN/WiFi/

GP LAN/Paper Filing

system/SmartCaredatabase

Figure 6 - Possible ICT Infrastructure Components for ICP-Discharge


Possible ICT Infrastructure Components for ICP-Discharge

Hospital LAN &WiFi

HospitalLAN/WiFi/Paper

Filing System

HospitalLAN/Paper Filingsystem, GP LAN

HospitalLAN/WiFi &Community

H&SCLAN/WiFi/Paper

Filing system

HospitalLAN/WiFi &

Community H&SCLAN/WiFi/SPA,

Call entre/PaperFiling system

HospitalLAN/WiFi &

Community H&SCLAN/WiFi/GP

LAN/Paper Filingsystem



system, CareRecipient’ home










SPA/Call CentreLAN/WiFi



system



system

Hospital LAN/WiFi& Community

H&SC LAN/WiFi/GP LAN/PaperFiling system


H&SCLAN/WiFi/GP



H&SCLAN/WiFi/GP


Figure 7 and 8 depict the different information and communication technology infrastructure

components that could be allocated amongst the pathway functions to provide communication of



the integrated care information along the workflow. Due to the various legacy installations at the

pilot sites, the infrastructure elements listed range from the use of paper based systems to

broadband telecommunications access.

Figure 7 - Information Sharing Mechanisms for ICP-LTCare


Information Communication & Sharing Mechanisms for ICP-LTCare

ReferralinformationCommunity

Health record

Referralinformation

Community SocialCare record

Assessment infoCommunity H&SC

record, systemgeneratedmessage

ConsentEmail, Integrated

record, systemgenerated

message, Fax,phone

Care PlanEmail,

Integratedrecord, Fax,

phone

Care Co-ordination

Email, Integratedrecord, system

generatedmessage, Fax,Phone, letter



generatedmessage, Fax,Phone, shared

paper diary




paper diary




paper diary

Self monitoringinfo

Email, Tele-system, web-based system,

Integratedrecord, phone


Services infoEmail, Integrated


message, Fax

Review & Re-assessment infoEmail, Integrated


message, SMS,Fax phone, letter

Temporaryadmission info


generatedmessage, Fax,

Phone

Discharge infoEmail, Integrated


message, Fax,letter



Figure 8 - Information Sharing Mechanisms for ICP-Discharge


Care PlanEmail,

Integratedrecord,Fax,

phone

ConsentEmail,

Integratedrecord,

system generatedmessage,

Fax, phone

Assessment infoHospital Healthrecord, system

generatedmessage

Admission andDischarge date

infoHospital Health

record

Discharge infoEmail,

Integratedrecord, system


Care Co-ordination



Self monitoringinfo

Email,Tele-system,

web-based systemIntegrated

record,phone




paper diary




paper diary




paper diary


Services infoEmail, Integrated


message, Fax

Discharge infoEmail, Integrated

record, systemgeneratedmessage,

Fax, letterReview & Re-

assessment infoEmail, Integrated


message, SMS,Fax, phone, letter

Discharge &Referral info

Email, Integratedrecord,

system generatedmessage,

Fax, phone,letter

Re-admissioninfo


generatedmessage, Fax,

Phone

Information Communication & Sharing Mechanisms for ICP-Discharge

2.3 SmartCare Users and User Rights

There are five classes of users/actors of the SmartCare system:

Staff of Health Care Provider (HCP): Uses SmartCare system to develop/modify/reviewclinical care to be followed by and administered to home care recipients’

Staff of Social Care Provider (SCP): Uses SmartCare system to develop/modify/review socialcare to be followed by and administered to home care recipient

(Voluntary) staff of third sector care provider (TCP): May or may not use SmartCare system

Informal/Family Care Provider (I/FC): Uses SmartCare system to review/document caredelivered to home care recipient

Care Recipient (CR): Uses SmartCare system to review/document self-care delivered

The SmartCare system should offer the users the following rights when using the system.

Browsing: Access to read the information in the SmartCare system

Editing: Ability to modify information in the SmartCare system

Upload: Ability to add information to the SmartCare system

Requestor: Ability to request information or an action in the SmartCare system

Distributor: Ability to distribute information to/from the SmartCare system



Table 1: User Access Rights

User/Access Browsing Editing Upload Requestor Distributor

HCP Health care provider x x x x x

SCP Social care provider x x x x x

TCP Third party voluntary careprovider

x

I/FC Informal/Family Caregiver x x x

CR Home carerecipient/patient

x x x

2.4 SmartCare Functional Blocks

Coordinated and simplified functional blocks derived from the previous extensive description of

SmartCare (see also D1.1) are listed below and depicted in Figure 9:

Enrolment and Consent

Integrated Care Plan Development/Modification

On-site (at patient home) delivery of care by HCP, SCP, TCP, I/FC or CR

Remote provision of care through telemonitoring or telecare

Documentation of care

Assessment of Care

Exit from pilot

Figure 9 - Simplified Functional Diagram for SmartCare

Enroll-ment andconsent

Care Plan

Onsiteprovision

of care

Remoteprovision

of care

Documentcare

Assesscare

PilotExit

These functional descriptions are shown in Table 2 along with input, output, users, system

interfaces, possible communication methods and standards and possible messaging methods and

standards.



Table 2: Functional Blocks and Standards Overview

SmartCareFunctionalBlocks

Inputs Outputs Users SystemInterfaces

PossibleCommunicationMethods/Standards

PossibleMessagingStandards

EnrolmentandConsent

PatientDemo-graphics,Dischargeplan,Request/Referral bycommunityresources

Dischargesummary andrecommendation for care

HCP,SCP,CR,I/FC

HealthcareRecord System;GP RecordSystem

Database based,electronicmessage based(e-mail, textmessage, phonecall, fax)

IHE ITI BPCC,PDQ;nationalstandards aspromulgatedby pilotsites;epSOS re-commendedstandards

Care Plan PatientInformation,Dischargesummary,possible careprotocols,

IntegratedProtocol/planfor carerecipient

HCP,SCP,TCP,I/FC,CR

HealthcareRecord, GPRecord System;Communityhealth and socialcare record(SmartCaredatabase?)

Database based;electronicmessage based(e-mail, textmessage, phonecall, fax);wireless orwired, aconfigureddevice, PCbased or mobilehandset;interface to hubcould be aspecificapplication orweb-based;TCP/IP; web-based protocols

HL7 CDA R2;IHE ITI XCA,XDM, XDE,XDS, XDS-SD,PDQ, PDQv3,PIX, PIXv3;IHE PCC MS,XPHR, CM

On siteprovisionof care

Patientinformation,carerequested/needed,scheduling ofcare

Care provided,modificationto care plan

HCP,SCP,TCP,I/FC,CR

CaseloadManagement andAppointmentscheduling;Communityhealth and socialcare record(SmartCaredatabase?)

Electronicmessage based(e-mail, textmessage, phonecall, fax);wireless orwired, aconfigureddevice, PCbased or mobilehandset;interface to hubcould be aspecificapplication orweb-based;TCP/IP; web-based protocols








Remoteprovisionof care

Vitalparametermonitoring,smart homemonitoring,educationalmaterial/content,scheduling ofcare

Vitalparametermeasurement,smart homemeasurementseducational/traininginformation/content,alerting of outof rangeparameters,virtualcoaching(audio/videoteleconfe-rencing)

HCP,SCP,TCP,I/FC,CR

Telehealth/Telecare system(sensors,aggregator (hub– which could bepaper record;wireless orwired, aconfigureddevice, PC basedor mobilehandset;interface to hubcould be aspecificapplication orweb-based),call centre

Electronicmessage based(e-mail, textmessage, phonecall, fax);Wireless(Bluetooth,ZigBee, WiFi,GSM(2G/3G/4G)),wired (PSTN,ISDN); TCP/IP;web-basedprotocols

IEEE 11073PHD datastandards,HL7 CDA R2;Continuacertification;IHE PCD DEC,RTM, ACM;IEEE802.15.4(ZigBee)

Documen-tation ofcare

Careprovided,modificationto care plan,vitalparametermeasure-ment, smarthome measu-rementseducational/traininginformation/content,alerting ofout of rangeparameters,virtualcoaching(audio/videoteleconfe-rencing)

Document /message/proof of careprovided,modificationto care plan,vitalparametermeasurement,smart homemeasurementseducational/traininginformation/content,alerting of outof rangeparameters,virtualcoaching(audio/videoteleconfe-rencing)

HCP,SCP,TCP,I/FC,CR

Telehealth/Telecare system, Callcentre,Communityhealth and socialcare record(SmartCaredatabase?);Paper based;wireless orwired, aconfigureddevice, PC basedor mobilehandset;interface to hubcould be aspecificapplication orweb-based









Assess-ment ofcare

Care Plan,careprovided byall means(on-site andremotely),CRprogressionthrough plan

Modificationto care plan,emergent careescalationrequest,recommendation for pilotexit

HCP,SCP

Communityhealth and socialcare record(SmartCaredatabase?);Health Record;GP recordsystem



Exit fromPilot

Care summary HealthcareRecord system,GP recordsystem




3 Defining Pilot Level ICT Functional Specification

This section presents the current view on functional specifications for implementing the two

SmartCare pathways in each of the first-wave pilot regions. Each subsection starts with a visual

representation of the current and future SmartCare ICT infrastructure and systems at pilot site level

followed by a description of initial local implementation plans of the SmartCare key functional

blocks.

3.1 Aragon

3.1.1 Aragon – Long-Term Home Care Support

Figure 10: ICP-LTCare: Current ICT Infrastructure & Systems - Aragon

Assesment ofuser’s needsSALUD EHRSALUD LAN

ConsentFormPaper

-

Monitoringplan

SALUD IS +Telemonit. ISSALUD LAN+

Internet

Social careSocial

recordsSCP LAN

Health carerecords

SALUD ISSALUD LAN

Informal careNO ISPaper

Telemonito-ring recordsTelemonito-

ring ISInternet

Monitoringplan

SALUD IS +Telemonit. ISSALUD LAN +

Internet

Exit infoSALUD IS +

Telemonit. ISSALUD LAN+

Internet

RelevantPatient

InformationSALUD EHRSALUD LAN

Aragon – Current ICT Infrastructure & Systems




Figure 11: ICP-LTCare: SmartCare ICT Infrastructure & Systems - Aragon

Assesment ofuser’s needsSALUD EHR+SCP User DBSALUD LAN +

SOCIAL LAN

Consent FormPaper

Initial IC PlanSALUD EHR+SCP User DB+ SmartCare

record

SALUD LAN

Coordinationof IC

SALUD IS +SCP IS +

SmartCarerecord

SALUD LAN +SCP LAN

+Intenet

Social careSocial records

SCP LAN

Health careReports

SALUD ISSALUD

LAN+Intenet

Informal caredocs

Propietary IS+ paper

Internet

TelecareTelemonit.

RecordsSALUD IS

Internet

ICdocumentation

SALUD IS +SCP IS +

SmartCarerecord

Internet+SALUD LAN +

SCP LAN

RelevantPatient

InformationSALUD EHR

SALUD LAN

ReassesmentIC Plan

SALUD IS +SCP IS +

SmartCarerecord


SCP LAN

Exit infoSALUD IS +

SCP IS +SmartCare

recordInternet

+SALUD LAN +

SCP LAN

RelevantPatient

InformationSALUD EHR +

SCP Userinterview

SALUD LAN

Aragon - SmartCare ICT Infrastructure & Systems


Entry point

Currently a patient living with one or more chronic condition enters this pathway when they receive

telemonitoring services following a referral from their GP. Patients have to meet the agreed

eligibility criteria which do not include social care needs at present.

There will be no difference to the Entry Point within the SmartCare pathway as the GP will continue

to be the person referring a patient into the pathway. However, if a patient fulfils the SmartCare

health inclusion criteria as agreed by the multi-disciplinary SmartCare Evaluation Committee, the

patient will also be referred to the local SCP for them to assess the person in relation to any social

care needs. The information will be recorded in the SALUD IS and the SCP User databases.

Assessment of the service user’s needs for integrated home care

At present, the GP undertakes an assessment of the patient’s health care needs and draws up the

telemonitoring plan which is entered into the SALUD IS. People who require assistance with using

their telemonitoring device are visited at home by the Red Cross when the measurements are

required to be taken and uploaded to the Telemonitoring IS.

In the SmartCare pathway the multi-disciplinary SmartCare Evaluation Committee, consisting of the

GP, SCP and SmartCare management team) will assess the needs of the user based on the referral

information contained in the SALUD and ICPs information systems. The assessment information will

be recorded in the SALUD EHR and the SCP User databases and updated following the first home

visit if necessary.

Enrolment into SmartCare pilot service and Consent

A key element on the SmartCare program is the SmartCare Evaluation Committee. The SmartCare

Evaluation Committee will be formed of a representative of every care provider and technical staff.

The Evaluation Committee will act as the SmartCare project manager and will be responsible to



manage and coordinate the identified actions within the SmartCare program. If a patient is

considered by the GP to be suitable for SmartCare, they will be referred to the SmartCare

Evaluation Committee and if the patient satisfies the inclusion criteria consent to participate will be

sought. The consent will be recorded in the SALUD IS and SCP systems.

Initial integrated home care plan

As there is no current fully integrated health and social care service provided within Aragon no

integrated home care plan is drawn up at present. However, the GP prepares a telemonitoring care

plan for the patients and Red Cross.

In the SmartCare pathway, the initial integrated home care plan will have a number of different

components depending on the patient’s needs. If they are to receive telemonitoring, the vital sign

parameters will be agreed and entered into the telemonitoring system. The patient will also be

provided with a contact point – the Integrated Care Co-ordination Centre - to be able to

communicate with their carers when needed. The IC centre will co-ordinate the caregivers working

in the territory and cities. Information will be recorded in the SmartCare record and made

available to the SALUD Information System and Social Care Providers Information System. All

aspects of an individual’s health and social care services will form part of the SmartCare record

unlike the current situation.

Co-ordination of integrated care delivery/revision of the initial care plan

The current pathway does not include information flow or co-ordinated plans and services between

the caregivers other than those individuals who are in receipt of telemonitoring services. The

communication that does take place is undertaken by phone and email.

The SmartCare pathway will enable a patient to receive a different level of health and social care

services dependent on their needs. The SmartCare record will hold all the assessment, care plan

and care delivery information on each patient and a member of the contact centre staff will co-

ordinate the action plan and schedule the appointments for the caregivers. The contact centre will

be able to access a common set of the patient’s data provided by the health and social care

information systems through the SmartCare record. The SmartCare record will provide a web portal

for all caregivers to access information about their service users on a role-based access model.

On-site provision of formal social care

Today the delivery of social care services is recorded in the social care information system. If a

third sector organisation is part of the social care delivery process, it will have its own record

keeping system which could be electronic or paper and this information is usually not included in

the SALUD and SCP records.

Within SmartCare as well as the social care information being available in the social care providers’

information systems, the new platform will create an integrated care record which will include

health, social care, informal care and any relevant telemonitoring information.

On-site provision of formal health care

Currently any services that are provided by health care providers in the patient’s home will be

recorded in the SALUD information system.

Within SmartCare as well as the health care information being available in SALUD, the new platform

will create an integrated care record which will include health, social care, informal care and any

relevant telemonitoring information.



On-site provision of informal care

Currently, information on informal care tasks provided by informal carers such as telemonitoring

tasks as those of taking vital sign measurements, or those onto the contractual relationship with the

patient, as for instance cleaning, cooking and the like is recorded on paper.

Within SmartCare, proprietary information systems and paper will be used by the informal carers

and this information will form part of the integrated care record available in the SmartCare record.

Remote provision of integrated care to the home (telecare, telemonitoring)

Aragon is currently piloting a telemonitoring service in which the patients take their own vital signs

measurements and upload the data to a monitoring portal. If required, alerts are generated and

the healthcare professionals respond to these when required.

A second telemonitoring project involves the Red Cross teams visiting the patient at home to

undertake the vital sign measurement and upload to the monitoring portal. Healthcare

professionals respond to any alerts generated.

In SmartCare, both telemonitoring approaches will be extended to a wider population and targeted

at particular cohorts of the population which will include those who are mobile having access to the

telemonitoring in a ’social/community’ environment. Aragon’s health card will facilitate this model

as it provides the unique patient identification mechanism for multi-use telemonitoring devices.

Integrated documentation of home care provided / self-care measures

Currently there is no integrated care documentation available. However, within SmartCare, the

central point will be the platform that will hold the information on the services that a user can have

benefit from, the actions provided, the designation of tasks to caregivers and the co-ordination

between caregivers. This platform will be the managed and co-ordinated by the Contact Centre and

will provide all the information that is required to provide an integrated care service through a web

portal that all caregivers, with appropriate permissions, will have access to.

Control /reassessment of the home care recipient

Currently, the care plans are monitored and revised by the different caregivers in isolation and the

information is communicated to other caregivers involved for them to enter into their record

systems.

In SmartCare, the monitoring and reassessment of the patient will be co-ordinated from the

Integrated Care Centre (contact centre) and the record will be updated accordingly. This updated

information will also be communicated to the relevant health and social care systems.

Temporary admission to hospital or care home

Today, if a patient is assessed as requiring an admission to hospital or care home from either the

scheduled re-assessment by a member of their care team or in an emergency, the information is

currently only likely to be documented in the SALUD information system.

Within SmartCare, the admission information in SALUD will be enhanced with access to the

SmartCare web portal. The patient will be reviewed by the SmartCare Evaluation Committee on re-

admission to determine whether or not they should remain in the project or be withdrawn. If a

person enters a care home temporarily, the relevant home caregivers will provide the care home

staff with the relevant information from the SmartCare web portal.



Exit point

Currently a patient is discharged to usual care if they no longer meet the criteria to receive

telemonitoring services. Within SmartCare, there will be a wider range of services available for the

patient to receive in line with their health and wellbeing status and they are less likely to stop

receiving services altogether but instead receive a ’lower level’ of care.

3.1.2 Aragon – Discharge Pathway

Figure 12: ICP-Discharge: Current ICT Infrastructure & Systems - Aragon

RelevantPatient


Assesment ofpatient’s

needsSALUD EHRSALUD LAN

Dischargereport

SALUD EHR/Paper

SALUD LAN

Social careSocial

recordsSCP LAN

Health carerecords

SALUD ISSALUD LAN

Informal careNO ISPaper

RelevantPatient

InformationSALUD IS

SALUD LAN

Care planSALUD IS

SALUD LANMonitoringprograms

Telemonito-ring Portal /

EHRSALUD

LAN/Internet

PermanentDischargeSALUD IS

SALUD LAN

Aragon – Current ICT Infrastructure & Systems

Notification of socialservices needed




Figure 13: ICP-Discharge: SmartCare ICT Infrastructure & Systems - Aragon

RelevantPatient


Assesment ofuser’s needsSALUD EHRSALUD LAN

ConsentFormPaper

Initial IC PlanSALUD EHR+SCP User DB+ SmartCare

recordSALUD LAN

Care planupon

dischargeSALUD EHRSALUD LAN

Coordinationof IC

SALUD IS +SCP IS +

SmartCarerecord

SALUD LAN +SCP

LAN+Intenet

Social CareReportsSCP IS

SCP LAN +Internet

Health careReports

SALUD ISSALUD

LAN+Intenet

Informal caredocs

Propietary IS+ paperInternet

TelecareTelemonito-

ringRecordsSALUD ISInternet

ICdocumentation

SALUD IS +SCP IS +

SmartCarerecord


SCP LAN

RelevantPatient


ReassesmentICPlan

SALUD IS +SCP IS +

SmartCarerecord


SCP LAN

Integrated ICPlan

SALUD IS +SCP IS +

SmartCarerecord

Internet+SALUD LAN

+ SCP LAN

Exitdocumenta-

tionSmartCare

recordInternet

Aragon – SmartCare ICT Infrastructure & Systems


Entry point

When a patient is admitted to hospital, information is entered into the SALUD electronic health

record including the anticipated discharge date.

There will be no difference to the Entry Point within the SmartCare pathway.


If any healthcare professional in the hospital thinks that the patient may have social care needs,

they will contact the social worker working at the Hospital. Together the health and social care

workers will assess the patient to determine whether or not they require integrated care when

discharged back to their home. An electronic notification is sent to the Social Care Information

System indicating that social care services will be required when the patient is discharged.

There will be no difference to the assessment process within the SmartCare pathway.


A key element on the SmartCare program is the SmartCare Evaluation Committee. The SmartCare

Evaluation Committee will be formed of a representative of every care provider and technical staff.

The Evaluation Committee will act as the SmartCare project manager and will be responsible to

manage and coordinate the identified actions within the SmartCare program. If a patient is

considered suitable for SmartCare, they will be referred to the SmartCare Evaluation Committee

and if the patient satisfies the inclusion criteria consent to participate will be sought.




As there is no current early discharge or hospital at home scheme provided within Aragon, no

integrated home care plan is drawn up.

In the SmartCare pathway, the initial integrated home care plan will have a number of different

components depending on the patient’s needs. If they are to receive telemonitoring, the vital sign

parameters will be agreed and entered into the telemonitoring system. The patient will also be

provided with a contact point – the Integrated Care Co-ordination Centre (IC) - to be able to

communicate with their carers when needed. The IC centre will co-ordinate the caregivers working

in the territory and cities. Information will be recorded in the SALUD Information System, Social

Care Providers Information System and the SmartCare record.

Discharge from hospital

Currently a discharge report is prepared on paper and entered into the SALUD electronic health

record which is shared between the Hospital, GP practice and community health staff.

Within SmartCare, the initial home care plan will also be included as part of the discharge report

and entered into the SALUD record which all caregivers have access to as will the Integrated Care

Co-ordination Centre.


The current discharge pathway does not include the provision of an integrated care service.

The SmartCare pathway will enable a patient to receive a different level of health and social care

services dependent on their needs. The SmartCare platform will hold all the assessment, care plan

and care delivery information on each patient and will co-ordinate the action plan and schedule the

appointments for the caregivers. The contact centre will be able to access a common set of the

patient’s data provided by the health and social care information systems. The SmartCare platform

will provide a web portal for all caregivers to access information about their service users on a role-

based access model.


The delivery of social care services is recorded in the social care information system. If a third

sector organisation is part of the social care delivery process, it will have its own record keeping

system which could be electronic or paper.

Within SmartCare as well as the social care information being available in the social care providers’

information systems, the new platform will create an integrated care record which will include

health, social care, informal care and any relevant telemonitoring information.


Currently any services that are provided by health care providers in the patient’s home will be

recorded in the SALUD information system.

Within SmartCare as well as the health care information being available in SALUD, the new platform

will create an integrated care record which will include health, social care, informal care and any

relevant telemonitoring information.




Currently, information on informal care tasks provided by informal carers such as telemonitoring

tasks as those of taking vital sign measurements, or those onto the contractual relationship with the

patient, as for instance cleaning, cooking and the like, is recorded on paper.

Within SmartCare, proprietary information systems and paper will be used by the informal carers

and this information will form part of the integrated care record available in the SmartCare web

portal.


Aragon is currently piloting a telemonitoring service in which the patients take their own vital signs

measurements and upload the data to a monitoring portal. If required, alerts are generated and

the healthcare professionals respond to these when required.

A second telemonitoring project involves the Red Cross teams visiting the patient at home to

undertake the vital sign measurement and upload to the monitoring portal. Healthcare

professionals respond to any alerts generated.

In SmartCare, both telemonitoring approaches will be extended to a wider population and targeted

at particular cohorts of the population which will include those who are mobile having access to the

telemonitoring in a ’social’ environment. Aragon’s health card will facilitate this model as it

provides the unique patient identification mechanism for multi-use telemonitoring devices.


Currently there is no integrated care documentation available. However, within SmartCare, the

central point will be the platform that will hold the information on the services that a user can have

benefit from, the actions provided, the designation of tasks to caregivers and the co-ordination

between caregivers. This platform will be the managed by the Contact Centre and will provide all

the information that is required to provide an integrated care service through a web portal that all

caregivers, with appropriate permissions, will have access to.


Currently, the care plan is monitored and revised by the different caregivers in isolation and the

information is communicated to other caregivers involved for them to enter into their record

systems.

In SmartCare, the monitoring and reassessment of the patient will be co-ordinated from the

Integrated Care Centre and the record will be updated accordingly. This updated information will

also be communicated to the relevant health and social care systems.

Re-admission

If a patient is re-admitted to hospital the information is documented in the SALUD information

system.

Within SmartCare, the re-admission information in SALUD will be enhanced with access to the

SmartCare web portal. The patient will be reviewed by the SmartCare Evaluation Committee on re-

admission to determine whether or not they should remain in the project or be withdrawn.

Exit point

Currently a patient is discharged to usual care or they get referred to telemonitoring on one of the

two projects within the region and this is documented in the SALUD information system.



In SmartCare, a patient could also transition onto the Long-Term Care at Home pathway and this

would be recorded in SALUD, the social care information system and the SmartCare record. A

patient can also withdraw from the SmartCare project at any time and this would be recorded in all

the information systems.



3.2 Southern Denmark

3.2.1 Southern Denmark – Long-Term Home Care Support

Figure 14: ICP-LTCare: Current ICT Infrastructure & Systems – Southern Denmark

Southern Denmark – Current ICT Infrastructure & Systems


Relevantpatient

informationMunicipal

ECRKMD CareLAN/Wi-Fi

Assesment ofneeds in each

systemSentinel/ KMD

CareLAN/Wi-Fi

IntegratedCareplanGP’s EHRSentinel/Municipal

ECRKMD CareLAN/ Wi-Fi

Coordinationif special

needsTelephone/

Meeting

Health Careservices

MunicipalECR/GP’s EHR

KMDCare/Sentinel

LAN/Wi-Fi

Home Careservices

MunicipalECRKMD CareLAN/Wi-Fi

Documentationin each system

KMDCare/Sentinel

LAN/ Wi-Fi

Temporal admissionGP/Municipality

Sentinel/KMD CareLAN/Wi-Fi

ControlGP/Municipa

litySentinel/KMD CareLAN/Wi-Fi

Relevantpatient

informationGPs EHRSentinel

LAN/Wi-Fi



Figure 15: ICP-LTCare: SmartCare ICT Infrastructure & Systems – Southern Denmark

Southern Denmark - SmartCare ICT Infrastructure & Systems


Relevantpatient

informationMunicipal

ECRKMD Care

Shared CareLAN/Wi-Fi

Assesment ofneeds in each

system + SharedCare

Sentinel/ KMDCare


Consent andShared Patient

planShared Care

PlatformLAN/Wi-Fi

IntegratedCarePlan

GP’s EHR/MunicipalECR

Sentinel/KMD CareShared CareLAN/ Wi-Fi


needsTelephone/

Meeting/Shared Care

Health Careservices

MunicipalECR/GP’s HER

KMDCare/SentinelShared CareLAN/Wi-Fi

Home Careservices

MunicipalECRKMD Care


InformalCarers/

RelativesShared CareLAN/Wi-Fi

Telehealth/Telecare

Shared CareNationaldatabaseLAN/Wi-

Fi/3G/Satelite

Documenta-tion in each

system +SharedCareKMD Care/

SentinelShared CareLAN/ Wi-Fi

Temporaladmission

GP/MunicipalitySentinel/KMD

CareShared CareLAN/Wi-Fi

ControlGP/MunicipalitySentinel/ KMD

CareShared CareLAN/Wi-Fi

ExitDocumenta-tion in each

system +SharedCare

Cosmic/KMDCare/SentinelShared CareLAN/ Wi-Fi

Relevantpatient

informationGPs EHRSentinel


Entry point

Currently, patients living with heart failure whose needs are not complex are mainly cared for by

their GP and the nursing team from the municipality. Specialists from the hospital monitor the

patients in outpatient clinics when required. If a patient’s overall health and wellbeing

deteriorates, the GP, hospital outpatient nurse or community nurse refers the patient to the

municipality for social care input into a person’s care or if the person is in receipt of social care

services and the SCP thinks they need input from health, the municipality IT system will message via

MedCom. The GP will respond with a message from the GP system via MedCom. Information on the

referral will be entered into either the municipality’s Social Care IT system, the municipality’s

health care system or the GP system.

The entry point will not change in SmartCare unless the person is already registered on the Shared

Care system.


Following the referral, the most appropriate member of the multi-disciplinary team will undertake a

comprehensive assessment to determine the level of health and social care input required using

information available in the health and social care systems. This assessment information is

recorded in Sentinel and KMD as well as Cosmic if the hospital is involved through MedCom

messaging.

In SmartCare, members of the multi-disciplinary team will be able to see the information in the

Shared Care system at the time of the assessment and know what services the person is already

receiving and when they are delivered. The MDT will also know whether the patient or informal

carers/family are contributing information to the Shared Care system and this will enrich the



assessment undertaken. The Shared Care system will be updated with the assessment information

when completed and a MedCom message will sent to the relevant actors.

Enrolment into SmartCare pilot service

In SmartCare, whether or not the patient is already registered on the Shared Care record, the nurse

will seek consent for them to participate in the project. If they are a new referral for Shared Care,

the nurse simply enters the patient’s CPR (personal security number) and the system retrieves the

basis information on the patient from the national database. After entering the basis information,

the nurse will choose the relevant clinical information and follow the predefined form to enter the

relevant data together with the patient.


Currently, there is no integrated home care plan as the Shared Care record only includes

information relating to a patient’s health care needs. In addition, the patient’s self-care

capabilities, e.g., exercise, diet, etc. are recorded in a section of the Shared Care record. The

activity calendar within the record also includes the appointments for rehabilitation and

preventative care carried out by care professionals in the municipality.

Within the SmartCare LTCare pathway, the initial integrated home care plan will be drawn up by

the heart failure outpatient nurse based on the information received from the municipality MDT

assessment. This plan is a structured conversation developed in collaboration with the

municipalities and is the patient’s tool for setting goals and keeping track with the agreed

treatment. This initial integrated home care plan is sent by MedCom message to the municipality.

Coordination of integrated care delivery/revision of the initial care plan

Currently at each point of contact with a care professional the patient or the care professional has

the opportunity to revise the needs of the patient and the services accordingly. Messages on any

changes will be automatically sent to the specific IT systems in the different organisations through

MedCom messages.

Currently the care co-ordination takes place in MDT meetings virtually and by telephone etc.

In SmartCare the care professionals have the same opportunity to revise the needs and services.

They can also coordinate the integrated care delivery between the health and social care services

through the Shared Care system.


In the present system, the social care services are organised and delivered separately to the

healthcare services within the municipality. These could typically be services such as cleaning,

bringing food, bathing, dressing and helping the patient to bed. The patients are also offered an

individual conversation with a coordinating social care professional if they are expected to have low

self-care ability. The patients are also offered a group-based educational programme, eg a 6 week

programme at a local facility, regarding lifestyle factors such as diet and exercise according to their

needs

The Shared Care record within SmartCare will be complemented by the rehabilitation worker with a

list of information in addition to the heart plan, where personal goals and expectations are

elaborated. The rehabilitation worker may also determine which information is to be shared in the

platform, such as guides for the patient, activities and notes. They will also look at the

measurements taken at the hospital or from home.




Today the on-site provision of health care may include physical rehabilitation, medication or

treatment of wounds and check-ups at the general practitioner. It will often be the heart failure

outpatient nurse who will assess the patient’s needs and inform the municipality and GP if home

care is required.

The SmartCare LTCare pathway will facilitate the inclusion of telemonitoring and video

conferencing where appropriate. This will enable the GP, municipality health team and hospital

clinical staff to see the patient’s measurements and notes before any scheduled appointments

which in themselves may be able to be substituted by virtual consultations. Any information the

care professionals enter into their own information systems will be available within the Shared Care

record as well as their own IT-system.


This care provision is not very prevalent in the Danish care system. However, within SmartCare,

with informed consent from the patient, a patient’s relatives will be able to see the information in

the Shared Care record in the same way that the patient will gain access. This will allow them to

support and monitor their loved ones.


Currently the only telemonitoring offered to patients with heart failure is to titrate their

medication.

In the Shared Care platform the patient is able to enter data from devices into the platform

themselves or connect devices that automatically update in the platform or via the national home

monitoring database (KIH). The measurements are stamped with the point of origin so that the care

professionals are able to see where the measurements are coming from. Videoconferencing will also

be made available in this service in a complimentary system, not yet defined. These possibilities

may replace physical meetings in the hospital or at the GP, and will also supplement the

measurements taken at the scheduled check-ups.


In the existing system each caregiver organisation is able to get an overview of defined variables

from their own systems. There is also a possibility to see statistical data on the type and amount of

electronic messages sent between the parties. The relevant data is stored in the individual systems

of the caregivers and national databases regularly collect information to get an overview across

systems.

In SmartCare through the Shared Care platform it will be possible to get a complete overview of the

patient’s heart disease and wellbeing based on the data entered. There is a very flexible

configuration which allows users to set up their own report templates with selected information

from the platform. This is only limited by the role-based access and rights of the individual ordering

the report. In addition the entire platform is based on presenting relevant and updated information

on the screen so that the caregivers or patient will not need to search around in the system after it.

The screen set-up can be customised to suit the individual user’s needs by applying role-based

access processes. It will also be easy to see historic data and have it presented in a visual and user-

friendly way.




As described in the care pathways the patient attends check-ups at 3, 6 and 12 months at the

hospital clinic after the heart plan has been drawn up. The patient is called in for a check-up at

their own general practitioner after the first year of check-ups at the hospital. Depending on the

level of functionality and self-care ability the home care may be reduced and the hospital passes

the responsibility of check-ups and monitoring measurements made from home to the GP. The GP

may also refer the patient to additional patient educational activities in the municipality by sending

them a referral. It is the GPs responsibility to be the main responsible caregiver on a long term basis

including evaluating the patient’s needs at a regular basis. However the municipality will also assess

the patient’s needs for home care services on a regular basis as they are the ones that deliver the

services.

In between check-ups the patient is able to see and enter relevant information into the Shared Care

record from home giving the caregivers a better insight into the patient’s needs. The involved

caregivers are able to access the Shared Care platform to see and enter relevant information to be

shared. Also the GP will be able to see the patient’s measurements and notes before the scheduled

check-ups and some of these check-ups might be able to be replaced by home-monitoring or

videoconferencing. This also means that the care professionals are better able to evaluate the

patient’s needs on a regular basis rather than on the scheduled visits.

Temporary admission an institutional setting (e.g. hospital, day care centre)

Currently it will probably be the GP or the municipality that notices a need for temporary admission

of the patient to hospital or care home and they will send an electronic referral to the hospital if

this is the place of admission.

Within SmartCare, the process will not change other than the Shared Care record being available to

the hospital staff on admission. The GP and/or municipality staff will provide any care home with

relevant information from the Shared Care record if a person is temporarily admitted to a care

home bed.

Exit point

The need for care is reassessed by the social caregivers and the GP on a regular basis and services

are adjusted accordingly. The patients will probably remain in the long term care pathway until

they are deceased.

Information is recorded in their individual systems.



3.2.2 Southern Denmark – Discharge Pathway

Figure 16: ICP-Discharge: Current ICT Infrastructure & Systems – Southern Denmark

Southern Denmark – Current ICT Infrastructure & Systems


Relevantpatient

informationHospital EHR

CosmicLAN/Wi-Fi

Assessmentof functional

levelHospital EHR

CosmicLAN/Wi-Fi

PreliminaryCareplan

Hospital EHRCosmic

LAN/ Wi-Fi

Discharge reportRehabiltation plan

EpicrisisHospital EHR

MunicipalECRGP’s EHR

LAN


needsIT-based/

Telephone/videoconf/

Meeting

Health CareservicesHospital

EHR/MunicipalECR/GP’s EHRCosmic/KMDCare/Sentinel

LAN/Wi-Fi

Home Careservices

MunicipalECR

KMD CareLAN/Wi-Fi

Documenta-tion in each

systemCosmic/KMDCare/Sentinel

LAN/ Wi-Fi

ReadmissionGP

SentinelLAN/Wi-Fi

ControlGP/Hospital

Sentinel/Cosmic

LAN/Wi-Fi

ExitDocumentationin each systemCosmic/KMDCare/Sentinel

LAN/ Wi-Fi



Figure 17: ICP-Discharge: SmartCare ICT Infrastructure & Systems – Southern Denmark

Southern Denmark – SmartCare ICT Infrastructure & Systems


Relevantpatient

informationHospitalEHR

CosmicLAN/Wi-Fi

Assesment offunctional levelHospitalEHR

CosmicLAN/Wi-Fi

Consent andShared

Patient planShared Care

PlatformLAN/Wi-Fi

PrelimenaryCareplan +

SharedPatient Plan

Hospital EHR+ Shared CareCosmic/SCPLAN/ Wi-Fi

Discharge reportRehabiltation planEpicrisis + Shared

Patient PlanHospitalEHR

Municipal ECRGP’s EHRSCP LAN


needsIT-based/

Telephone/videoconf/

Meeting/SCP

Health CareservicesHospital

EHR/Munici-palECR/

GP’s EHRCosmic/KMDCare/SentinelShared CareLAN/Wi-Fi

Home Careservices

MunicipalECR

KMD CareShared CareLAN/Wi-Fi

InformalCarers/

RelativesShared CareLAN/Wi-Fi

Telehealth/Telecare

Shared CareNationaldatabase

LAN/Wi-Fi/3G/Satellite

Documentationin each system+ Shared CareCosmic/KMDCare/Sentinel

SCPLAN/ Wi-Fi

ReadmissionGP

SentinelLAN/Wi-Fi

ControlGP/Hospital

Sentinel/Cosmic


ExitLong term

CareShared Care

SCPLAN/ Wi-Fi

ExitDocumenta-tion in each

system +SharedCare

Cosmic/KMDCare/Sentinel

SCPLAN/ Wi-Fi

Entry point

Currently, if a patient is admitted to hospital the hospital system sends a message to the patient’s

municipality informing them of the admission. The municipality’s system sends back a message

containing detailed information on the patient. This information is recorded in the hospital EHR

system – Cosmic. The patient may already have a Shared Care record as GPs, hospital staff and

social care professionals can enroll a patient in the platform. If this is the case, the admission

details will also be recorded in the Shared Care record.

There is no difference to the Entry Point within the SmartCare pathway.


In this phase the hospital nurse uses the information collected from the hospital, municipality, GP

and Shared Care record as part of the assessment to determine which health and social care

services the patient will need when discharged from the hospital. An electronic report is sent to

the municipality with relevant information on the patient’s treatment. The information is recorded

in the hospital EHR system Cosmic.


If the patient is seen in an outpatient clinic the nurse will seek consent to enter the patient’s data

and to share it with other relevant actors surrounding the patient’s treatment in the Shared Care

platform. The nurse will also give the patient information on the Shared Care platform and the

possibilities for getting access to their record themselves. The nurse also evaluates the patient’s

ability to perform home monitoring and if they are considered eligible they are given the

opportunity to get home monitoring equipment. This is then ordered at the Region, where

employees set up the devices at the patient’s home and at the same time introduce/train the



patient to use the device. The nurse simply enters the patients CPR (personal security number) and

the Shared Care platform retrieves the basic information on the patient from the national database.

After entering the basic information, the nurse will select the relevant disease and follow the

predefined template/form to enter relevant data together with the patient.

In the SmartCare discharge pathway, if the patient is not already registered in the Shared Care

record system, consent will be sought as well as consent to participate in the SmartCare project.


At the point of known discharge a preliminary rehabilitation plan is made by the hospital staff

where the patient’s needs are described. The information needed in this plan includes:

Full name and address of the patient

A description of the patient’s ability to function just before the event/disease that ledto the current hospital treatment. The plan also includes a description of the patient’susual ability to function related to body function, activity and level of participation.

A description of the patient’s ability to function when discharged which includes thepatient’s current ability to function related to body function, activity and participationthat can involve both the patient’s resources and limitations.

A description of the patient’s need of rehabilitation at the time of discharge. Thedescription has to include a clarification of which limitations the rehabilitation shouldfocus on. Furthermore this description has to consider the patient’s disabilities andpossible limitations regarding participation in activities and the rehabilitation ingeneral.

A statement if the patient needs rehabilitation in the hospital after being discharged.

A statement on the timeframe within the municipality of residence has the first contactwith the patient with a view to plan the course of rehabilitation. This also includes thepatient’s right to be guided regarding the possibility of choose between differentrehabilitation offers. In cases where the patient needs specialised rehabilitation at thehospital after being discharged, the rehabilitation plan has to state a timeframe withinthe hospital has to have the first contact with the patient.

Information about how the region of residence and the municipality of residence can becontacted.

This initial integrated home care plan is sent by MedCom message to the municipality within

48hours of admission.

Within the SmartCare discharge pathway, in addition to the above, when the patient returns to the

hospital for the first time after a discharge the nurse fills out a personal heart plan in the Shared

Care platform. This heart plan is a questionnaire developed in collaboration with the municipalities

and is the patient’s tool for setting goals and keeping track with the agreed treatment. See an

example of the heart plan as well as a translation as attached documents. If the patient is not yet

included in the Shared Care platform she enters the patient’s social security number and chooses

the patient’s condition. This enables her to fill out the heart plan in the platform with the patient

after they have given their consent. Afterwards they fill out the questionnaire together setting

goals, entering measurements and scheduling check-ups after 3, 6 and 12 months.


When the patient is ready to be discharged the responsible nurse fills out a discharge report in the

hospitals IT-system, which she sends to the homecare department in the municipality. This report

includes information such as:

General information on the patient and their relatives contact information



Information on the cause of the admittance and the treatment delivered while in thehospital

The patient’s current need for further treatment and medicine

An evaluation of the patient’s functional level and a description of which social careelements that need to be put in place in the patient’s home.

The patient is discharged and the hospital nurse sends the discharge report to the municipality

stating the patient’s needs in terms of home care and a notice to the general practitioner. She also

sends a rehabilitation plan to the municipality for physical rehabilitation. She gives the patient a

paper-based edition of the heart plan after the first check-up meeting.

Within SmartCare, instead of filling out the heart plan in paper the nurse will complete the

template/form in the Shared Care platform. As the heart plan is available in the Shared Care

platform adjustments are easily made at any point in time and shared with the other involved

caregivers and the patient. As the patient has access to the information and can add measurements

and notes, revisions can be made more on a need-basis rather than on a plan-basis. The nurse can

also give the patient access to home monitoring and videoconference possibilities making some of

the visits to and from care professionals unnecessary. This also means that the patient may be able

to be discharged earlier as contact via telemonitoring/telecare services in the patient’s home will

be possible.


A review of the patient once discharged is made to determine if there has been a significant change

to the patient’s functional level. If there is a significant change the hospital is urged to host a

videoconference between the hospital professionals, the GP, the municipality and the patient. In

the conference a co-ordinated plan for the level of care after discharge should be made and the

responsibility between the caregivers is divided. If the change is not significant it is the hospital

nurse evaluates the need for at home care and sends this in the above mentioned report. The

hospital nurse also sends a plan for physical rehabilitation to the training facility at the

municipality, where she describes the patient’s need for training. These messages are all

automatically sent to the specific IT-systems in the different sectors through MedCom.

At each point of contact with a care professional the patient or the care professional has the

opportunity to revise the needs of the patient and the services accordingly. In the existing system

however this revision is only made by request from the patients themselves or at planned contacts

with caregivers. The heart plan is paper-based, which makes it hard to revise. The Shared Care

platform within SmartCare will have an alarm-mechanism that allows the care professionals to be

alerted when a measurement exceeds an agreed value. This means that the care professionals will

have an opportunity to intervene faster than in the existing system.


When the patient returns home the social care is provided according to the message/report sent by

the hospital nurse. This could typically be a home care worker from the municipality which provides

services such as cleaning, bringing food, bathing, dressing and helping the patient to bed. These

services depend on the needs described by the hospital nurse. The patients are also offered an

individual conversation with a co-ordinating social care professional if they are expected to have

low self-care ability. The patients are also offered a group-based educational programme of 6 weeks

at a local facility, regarding lifestyle factors such as diet and exercise according to their condition.

The Shared Care record within SmartCare will be complemented by the rehabilitation worker with a

list of information in addition to the heart plan, where personal goals and expectations are



elaborated. The rehabilitation worker may also determine which information is to be shared in the

platform, such as guides for the patient, activities and notes. They will also look at the

measurements taken at the hospital or from home.


Today the on-site provision of health care may include physical rehabilitation, medication or

treatment of wounds and check-ups by the general practitioner. All these services are assessed at

the time of discharge and the patient’s needs are re-evaluated before interventions such as physical

rehabilitation commences. Here a 6 week long programme is made according to the individual’s

needs – either in groups or individually. The patient sees their local GP for annual check-ups after

the first year after discharge. If there is a need for rehabilitation this can either be performed at a

local training facility or at the patient’s home depending on the patient’s ability to transport

themselves.

The SmartCare discharge pathway will facilitate the inclusion of telemonitoring and video

conferencing where appropriate. This will enable the GP and hospital clinical staff to see the

patient’s measurements and notes before any scheduled appointments which in themselves may be

able to be substituted by virtual consultations. Any information the caregivers enter into their own

information systems will be available within the Shared Care record as well as their own IT-system.


This care provision is not very prevalent in the Danish care system. However, within SmartCare,

with appropriate permissions, patients’ relatives will be able to see the information in the Shared

Care record in the same way that the patient will gain access. This will allow them to support and

monitor their loved ones.


Currently the only telemonitoring offered to patients with heart failure is to titrate their

medication.

In the Shared Care platform the patient is able to enter data from devices into the platform

themselves or connect devices that automatically update in the platform or via the national home

monitoring database (KIH). The measurements are stamped with the point of origin so that the care

professionals are able to see where the measurements are coming from. Videoconferencing will also

be made available in this service in a complimentary system, not yet defined. These possibilities

may replace physical meetings in the hospital or at the GP, and will also supplement the

measurements taken at the scheduled check-ups.


In the existing system each caregiver organisation is able to get an overview of defined variables

and information from their own systems. There is also a possibility to see statistical data on the

type and amount of electronic messages sent between the parties. The relevant data is stored in

the individual systems of the caregivers and national databases regularly collect information to get

an overview across systems.

In SmartCare through the Shared Care platform it will be possible to get reports based on the data

entered. There is a very flexible configuration which allows users to set up their own report

templates with selected information from the platform. This is only limited by the role-based access

and rights of the individual ordering the report. In addition the entire platform is based on

presenting relevant and updated information on the screen so that the caregivers or patient will not

need to search around in the system after it. The screen set-up can be customised to suit the



individual user’s needs. It will also be easy to see historic data and have it presented in a visual and

user-friendly way.


As described in the care pathways the patient attends check-ups at 3, 6 and 12 months at the

hospital clinic after discharge. After this, the patient is called in for a check-up at their own general

practitioner after the first year of check-ups at the hospital. Depending on the level of functionality

and self-care ability the home care may be reduced and the hospital passes the responsibility of

check-ups and monitoring measurements made from home to the GP. The GP may also refer the

patient to additional patient educational activities in the municipality by sending them a referral. It

is the GPs responsibility to be the main responsible caregiver on a long term basis including

evaluating the patient’s needs at a regular basis. However the municipality will also assess the

patient’s needs for home care services on a regular basis as they are the ones that deliver the

services.

In between check-ups the patient is able to see and enter relevant information from home giving

the caregivers a better insight into the patient’s needs. The involved caregivers are able to access

the Shared Care platform to see and enter relevant information to be shared. Also the GP will be

able to see the patient’s measurements and notes before the scheduled check-ups and some of

these check-ups might be able to be replaced by home-monitoring or videoconferencing. This also

means that the care professionals are better able to evaluate the patient’s needs on a regular basis

rather than on the scheduled visits.

Re-admission

If a GP decides to re-admit a patient to hospital an electronic referral will be sent to the hospital.

In SmartCare, the only difference in the process will be that the patient is already entered into the

Shared Care platform and the involved caregivers will have the electronic referral if a GP has

admitted the patient, together with the historic data to help inform their decision making. If the

patient is admitted as an emergency, the information in the Shared Care record will be available to

the caregivers.

Exit point

The patient will probably remain in the Shared Care platform on the Long-Term Care at Home

pathway until they are deceased or wishes to be taken out of the system.



3.3 Scotland

3.3.1 Scotland – Long-Term Home Care Support

Figure 18: ICP-LTCare: Current ICT Infrastructure & Systems – Scotland

Scotland – Current ICT Infrastructure & Systems


Communityhealth

IntegratedH&SC

LAN/WiFi/2/3/4G, Broadband,

GP LAN, ER

Communitysocial careIntegrated

H&SCLAN/WiFi/2/3/4G, Broadband,

ER

Assessment infoIntegrated H&SCLAN/WiFi/2/3/4G, SmartCaredatabase, ER,

Initial Screening,Triage

ConsentIntegrated H&SC

LAN/WiFi/2/3/4G,ER, SmartCaredatabase, GP

system, SmartCarePrevention Package

Integrated Care PlanIntegrated H&SC

LAN/WiFi/2/3/4G,SmartCare database,

MultifactorialAssessment,

Community H&SC ER,GP system

Care Co-ordination

Integrated H&SCLAN/WiFi/2/3/4G

, SmartCaredatabase, ER

Health careIntegrated H&SC

LAN/WiFi/2/3/4G,SmartCareatabase,

Signposting toprimary care services,

EquipU, Rehab,Videolinked Exercise

Informal CareIntegrated H&SC

LAN/WiFi/2/3/4G,SmartCare

database, Invigor8,Wii Fit, Online

Advice, Systems,e.g. LIU

Social careIntegrated H&SC


Online Self-Assessment, Real-

time HomecareMonitoring,Enablement

Telehealth/TelecareIntegrated H&SC


SPA, Call Centre,Pulmonary Rehab,

Heart Failure

IntegratedDocumentation

Integrated H&SCLAN/WiFi/2/3/4G,

SmartCaredatabase, Shared

Outcomes and Self-Care Measures

Control/ReviewIntegrated H&SC

LAN/WiFi/2/3/4G,SmartCare

database, SIMS,Shared Outcomes

and Self-CareMeasures

Admission toInstitution

Hospital LAN/WiFi &Community H&SC

LAN/WiFi/GPLAN/Residential &

Nursing homeLAN/WiFi,

SmartCare database

ExitIntegrated H&SCLAN/WiFi/2/3/

4G,SmartCaredatabase,

IntegratedDischarge Info



Figure 19: ICP-LTCare: SmartCare ICT Infrastructure & Systems – Scotland

Scotland- SmartCare ICT Infrastructure & Systems


Communityhealth

Communityhealth LAN,Telephone,Paper Filing

System, GP LAN

Control/ReviewSocial Care

System, HealthCare System,Paper record,Email, Case

Discussion, Fax,Telephone,

Letter

Communitysocial Care

LAN,Telephone,Paper Filing

System

Assessmentinfo

Social CareSystem/ER,Health CareSystem/ER,Paper Filing

System

ConsentSocial CareSystem/ER,Health CareSystem/ER,Paper Filing

system, GP LAN

Care PlanSocial Care

System, HealthCare System,Paper Filing

system,Emailing, Fax, GP

LAN

Care Co-ordinationSocial Care System,Health Care System,Paper Filing system,

Case Discussion,Emailing,

Telephone, Letter,Fax, GP LAN

Health careSocial Care System,Health Care System,

Case Discussion,Community

Broadband, PaperDiary system

Care Recipient’shome Broadband,

Paper record

DocumentationSocial Care

System, HealthCare System,Paper record,

Service User self-care plan,

Homecare Real-time Monitoring

system

Admission toInstitution

Fax, Telephone,Paper Record

ExitSocial Care

System, HealthCare System,Paper record,

Social careSocial Care System,Health Care System,




Paper record

Informal careSocial Care System,Health Care System,




Paper Record

Telehealth/TelecareEmail, Telephone,Fax, Web-based

System, Call Centre

Entry point

At present, people who are at risk of falling or have already had a fall will be sent in a range of

different directions for support. When they have fallen on more than one occasion it is more likely

that the person will come to the attention of a professional engaged in falls prevention work, e.g.

exercise, physiotherapies, equipment provision. Either way, in the main the exchange of

information will be via telephone call with a paper record or referral form following.

Within SmartCare, a single point of contact will be created which all the various agencies and

citizens can contact. This point of contact will be made easily accessible through a variety of

familiar routes including GP surgeries, health and social care websites, community TV stations as

well as telephone access.


Currently, it is usual for both health and social care professionals to carry out their own assessments

and the information recorded in their own systems and it is not systematically shared. A

comprehensive assessment of an older person’s health and social care needs is undertaken if a

significant health issue has occurred or a significant event occurs at home which compromises their

ability to cope independently e.g. carer’s illness or can no longer manage personal care.

There is no consistent use of screening questions prior to someone receiving interventions towards

falls prevention.



The SmartCare project will provide an initial screening to everyone referred. This will consist of

some basic screening questions administered by the Contact Centre, which will determine whether

they are eligible and would benefit from the falls prevention the service or if they should be

signposted elsewhere. The answers to the questions will be recorded in the SmartCare system.

Triage – the next stage is triage where a member of the multi-disciplinary falls prevention team will

examine the person’s health, social care and falls screening information to determine the level of

risk and intervention required for the individual and then they will be offered the appropriate

programme.

Multi-factorial Assessment – where the level of need is complex a multi-factorial assessment will be

carried out by the most appropriate practitioner who will pull together the information which

provides a holistic picture of the person’s needs and their carer’s needs. This will be recorded in

the SmartCare record.


Following the screening/assessment to determine the level of risk and interventions to be offered,

consent to participate in SmartCare will be sought and recorded in the SmartCare record.


The current fall prevention service does not include the provision of an integrated home care plan.

Within SmartCare, an integrated falls prevention plan will be drawn up and this could include

interventions and self-care activities to be undertaken in the home or other environments.


At present there is no consistent approach to co-ordinating the care of an individual as the care

plans are recorded on different systems for health and social care. Some practitioners within joint

health and social care teams have access to both systems. No agency will has a comprehensive

picture of the different interventions being carried out to support the person. Case discussions are a

key mechanism for sharing information. If an integrated plan is agreed it will be shared in paper

format and filed separately in each agency’s paper file of the person.

SmartCare will enable an integrated falls prevention plan to be agreed between all the caregivers

and the care recipient. The plan will sit on the SmartCare database and shared with all key agencies

that are required to provide input including the recipient and their main carers if appropriate. The

plan would be entered into the SmartCare database. A review timetable would also be agreed and

recorded in the database.

Onsite provision of health care

Currently, each area in the Scottish deployment site has different on site health care provision in

relation to falls prevention in terms of interventions provided and range of care practitioners

involved.

In the SmartCare falls pathway service there will be the need to support people with long term

conditions and we will use telemonitoring to promote self-management and enable people to

remain at home where possible. The telemonitoring information will be viewed by the patient and

their GP practice. Healthcare practitioners will be able to access the SmartCare database to view

information on the patient and input changes where required.



Onsite provision of social care

The exchange of information across health and social care happens in a variety of ways by

telephone, fax, emails and written referrals. In some locations health personnel have access to

social care information systems and social care workers have access to healthcare information

systems. In some areas health care staff will input into the social care system and they will also be

required to record a duplicate observation in their own organisation’s system.

The community alarm/telecare systems are well established across Scotland. The call handlers input

information to the system regarding a specific incident or changes regarding the service user’s

circumstances. Information is not directly fed in by health or social care practitioners or the GP

surgery. Call handler will input specific information regarding the service user from all of these

sources. The system can produce activity reports on each individual and indicate trends in

behaviour. It can also produce overall performance reports on level of calls call outs and response

times.

In the SmartCare project all care practitioners will input into the one system. The interventions

they carry out and support the person with will be part of the agreed care plan. Progress will be

monitored and recorded in this system. Progress will be measured against the desired outcomes as

agreed with the service user.

Onsite provision of informal care

Informal carers currently play a significant part in the delivery of a support plan for a person who is

attempting to increase their independence and prevent falls. The model of integration in Scotland

already includes informal carers and the third sector is included at both an operational and

strategic level. At present a carer’s view will be taken into consideration when a care plan is being

developed. The carer’s needs can also be assessed and a support plan put in place to ensure they

can continue to care. Carers can have a paper copy of the care plan for person they are caring for,

with their consent, and a paper copy of their own support plan. The main method of communication

with service users and carers is by phone, letter or through a face to face meetings/case

discussions. IT does not play a significant part in communication with service recipients and

families. General information provision is the main area where ICT plays a part. There are a broad

range of good quality websites which support carers.

The third sector and independent sector are now considered equal partners in the redesign of

services for older people across Scotland. The third sector is a major player in the promotion of the

health and wellbeing agenda. They provide exercise classes, walking groups, befrienders to support

people to get out and about. The independent sector is a major provider of Homecare services and

Care homes. At present information will be shared with them in relation to an individual’s package

of care. In the main this will be a paper copy of their social care assessment. They currently have

no access to health and social care information systems but information will be shared with them on

a need to know basis.

In the SmartCare pilot, where appropriate, the third and independent sector will access the shared

system and input information.

Remote provision of health and social care to the home

Across the deployment site in Scotland there is a range of telecare and telemonitoring already in

place but there is no consistent provision.

The SmartCare service will provide a range of telecare and telemonitoring services in line with the

different levels of risk in relation to falls prevention and any associated chronic conditions such as

COPD, heart failure and diabetes.



Integrated documentation of home care provided/self-care measures

At present there are very limited examples of integrated documentation. The Community

rehabilitation and enablement services are being developed across the partnership sites and good

examples of integrated paper care plans can be evidenced. Integrated ICT systems within an

organisation can be evidenced, e.g. the out of hours services have access to ICT systems and in an

emergency can access the full summary health history and up to date position with the person.

Protocols are in place to alert the out of hours service to the day’s events if there is a risk of

continued activity.

The SmartCare service will establish an integrated care plan for falls prevention which the service

user will have access to as well as practitioners. A single ICT system will be agreed at each

deployment site for the use of falls pathway planning and monitoring.

Control re-assessment/review

As with the assessment, co-ordination an integrated documentation, there is currently no consistent

approach across the Scottish deployment site in relation to monitoring and re-assessing the person

and therefore no formal information recording process.

Within SmartCare, the system will include the on-going monitoring of a person’s progress in

reducing their level of risk and agreed re-assessment dates recorded in the integrated care plan.

Temporary admission to institution or hospital

Although a falls prevention pathway would not ordinarily include an admission to hospital or care

home, it is recognised that there may be people on the pathway who have other health or social

care conditions which may result in them being admitted to hospital or to a care home temporarily.

Currently, if a person does need to be admitted, it is unlikely that all the relevant information in

relation to their health and social care needs will be available to the institution.

Within SmartCare, the integrated care record will follow the person and be updated accordingly.

Exit point

Individuals who have followed the falls prevention services in their area and reduced their risk are

currently ‘discharged’ from the pathway but are likely to experience on-going fluctuations in their

health and wellbeing as they age.

Within the SmartCare system, people who have previously been referred assessed and engaged in

services to reduce their risk of falling and subsequently ‘discharged’ will be able to be re-referred

and access appropriate services in a more streamlined way as the system will already have a record

of the person.



3.3.2 Scotland – Discharge Pathway

Figure 20: ICP-Discharge: SmartCare ICT Infrastructure & Systems – Scotland

Scotland – Current ICT Infrastructure & Systems


Discharge InfoEmailing,

telephone,paper filing

systemLAN, CaseDiscussion

Assessment InfoSocial Care

system/ER, HealthCare system/ER

Paper Filing (SSA),LAN, Telephone,

Emailing, Casediscussion

EnrolmentHealth Care

system/ER, SocialCare system/ER

Paper Filing (SSA),LAN, Emailing,

Telephone, CaseDiscussion

Initial Care PlanSocial Care

system/ER, HealthCare system/ER

Paper Filing (SSA),LAN, Emailing,

Fax, Portal

DischargeHealth Caresystem/ER,Social Caresystem/ERPaper Filing(SSA), LAN,

Emailing,Telephone, Fax

Care Co-ordinationHealth Caresystem/ER,Social Caresystem/ERPaper Filing(SSA), LAN,

Emailing,Telephone,

Fax, GP, Casediscussion

Social CareHealth & Social

Care system, PaperDiary & Record,Case Discussion,

Telephone,Community & Care

Recipient’sBroadband

Health CareHealth Care

system, Social Caresystem, Paper Diary

& Record, CaseDiscussion,Telephone,

Community & CareRecipient’s

Broadband

Informal CareHealth Care

system, Social Caresystem, Paper Diary& Record, Case Dis-cussion, Tel., Com-

munity & Care Reci-

pient’Broadband

Telehealth/TelecarePaper Record, CaseDiscussion,Telepho

ne, Emailing,Community & Care

Recipient’sBroadband, AlarmReceiving Centre

DocumentationHealth & SocialCare systems,Paper Record,Service User

self-care planEmails, Home-care Real time

monitoringsystem

Readmission toHospital

Health & SocialCare systems, Paper

Record,Emails, Fax, CaseDiscussion, AlarmReceiving Centre,Telephone, Letter

Control & ReviewHealth & Social

Care systems, PaperRecord,

Emails, Fax, CaseDiscussion, AlarmReceiving Centre,

Telephone, Letter.

Exit Point-Transition

Health & SocialCare systems,Paper Record,

Emails, Fax,Case

Discussion,

Exit Point-Disenrollment

Health &Social Care

systems,Paper Record,

Emails, Fax,Case

Discussion



Figure 21: ICP-Discharge: SmartCare ICT Infrastructure & Systems – Scotland

Scotland – SmartCare ICT Infrastructure & Systems


Entry PointIntegrated

H&SC,LAN/WiFi/2/3/

4G,Broadband, GP,

ER, InstantMessaging

Assessment InfoIntegrated H&SC,

LAN/WiFi/2/3/4G,Broadband,

SmartCare Data BaseER, Tablets/I-Pad.Initial Screening

Triage

EnrolmentIntegrated H&SC,


SmartCare DataBase, ER, Tablets/I-

Pad. InstantMessaging

Initial Care Plan

Integrated H&SC,LAN/WiFi/2/3/4G,

Broadband, SC DataBase, ER, Tablets/

I-Pad. Instant Messa-

ging, MultifactorialAssessment, GP

system,Telehealth systems

DischargeIntegrated H&SC,


SmartCare DataBase ER, Tablets/

I-Pad. InstantMessagingGP system,

Telehealthcaresystems

Care Co-ordinationIntegrated H&SC&Alarm Receiving

Centre,


SmartCare DataBase, ER, Tablets/

I-Pad. Instant

MessagingTelehealthcare

systems

Social CareIntegrated H&SC& Alarm

Receiving Centre,LAN/WiFi/2/3/4G,

SmartCare Data Base,Tablets/I-Pad. Instant

Messaging, TehealthcareEnablement, Real timeHome Care Monitoring,

On-Line Self-Assessment

Health Integrated

H&SC& Alarm ReceivingCentre - LAN/WiFi/2/3/

4G, SmartCareDataBase, Tablets/I-Pad.

Instant Messaging,

Integr. Aids& Adapta-tions & Telehealthcare

systems, Signposting toprimary care, Rehab,Videolinked Exercise

Informal Care

Integrated H&SC& AlarmReceiving Centre,

LAN/WiFi/2/3/4G,SmartCare Data BaseTablets/I-Pad. Instant

Messaging OnLine advicesystems, Invigor8

Telehealth/TelecareIntegrated H&SC& Alarm

Receiving CentreLAN/WiFi/2/3/4G,

SmartCare Data BaseTablets/I-Pad. InstantMessaging, Integrated

Telehealth caresystems,SPA

DocumentationIntegrated H&SC&Alarm Receiving

Centre

LAN/WiFi/2/3/4G,SmartCare Data

BaseTablets/I-Pad.

Instant Messaging,

Shared Outcomes,Self-Care Measures

Readmission toHospital

Hospital LAN/ WiFi,Community

H&SC& AlarmReceiving Centre

LAN/WiFi/GP LAN,SmartCare DB

Instant Messaging,

Control &Review

Integrated H&SC&Alarm Receiving

CentreLAN/WiFi/2/3/4G,

SmartCare DBShared Outcomes,

Self-CareMeasures

SIMS

Exit Point -Transition


Centre LAN/WiFi/2/3/4G,

SmartCare DataBase InstantMessaging,

Tablets/I-PadsCase discussion

Exit Point -Disenrollment


CentreLAN/WiFi/2/3/4G,

SmartCare DataBase

Instant Messaging,Tablets/I-Pads

Entry Point

At present when a patient is being prepared for hospital discharge a variety of different approaches

will be applied depending on the complexity of the person’s medical condition and the level of

informal support (family) the patient has. The systems used at this point will include the Hospital

Patient Administration System, telephone, paper and faxing to external agencies and family. The

hospital and GP do use the same information system, but this is not always up to date with the

admission information or impending discharge date.

This will not be different in the SmartCare pathway.


At present in a hospital setting, once a doctor has indicated that a patient is ready for discharge,

patients with non-complex needs are assessed by ward nursing staff or some deployment sites have

Care at Home managers who visit people on the ward. Ward staff complete a paper-based

assessment and telephone and fax this information to social services. The assessment will include

the person’s social circumstances and wellbeing.

In the SmartCare pathway all patients will have their social circumstances and wellbeing assessed as

part of the admission and assessment process and if the patient is assessed as having complex social

care needs, social workers will lead on undertaking a full multi-disciplinary assessment in order to

plan the home care requirements on discharge. The assessment will be entered into the SmartCare



database which will be able to be accessed by all relevant caregivers with the appropriate role-

based access permissions.


Patients requiring referral to the falls prevention service in addition to any other health or social

care needs as a result of their admission will be eligible for SmartCare and their consent will be

sought. The consent will be entered in the Hospital record as well as the SmartCare database.


Currently a paper home care plan is drawn up by ward staff as part of the assessment process. The

information is faxed and/or telephone to the respective community health and social care teams.

Within SmartCare, the home care plan will be entered into the SmartCare system which will be

viewed by all medical, nursing, therapy, and social care staff as well as the patient themselves if

possible. The information will be a comprehensive overview of the reason for admission and home

care needs on discharge.

Discharge

Currently when a patient is discharged, the hospital ward staff telephone the GP if there is any

urgent information to share and the discharge summary is provided in a letter and handed to the

patient to take to their GP. The discharge summary will also be input on the information system

shared by hospital and GP practices but this can up to a week or more to be completed.

In SmartCare the discharge information will be entered into the SmartCare database along with the

home care plan details so that all those caregivers involved in a person’s care can have access to

update information. In the short term, the SmartCare database will not alleviate the need for

health and social care staff to enter relevant information into their own IT systems where this is the

current practice.


At present care co-ordination is not a key feature in the delivery of falls services and a number of

different information systems and communication mechanisms are used to bring together

appropriate information to inform the care services such as telephone, fax, paper records and

different IT systems used in the health and social care organisation.

In the SmartCare system the one information system will be used and this will improve integrated

working and co-ordination.

On-site provision of formal social care, health care and informal care

The ongoing treatments/interventions required by a patient when they return to the community are

currently recorded on several different systems, for example, the ‘care at home’ care plan will be

recorded on the home care information system which sits within the local authority. Health care

staff do not have access to this system. The rehabilitation team will have a separate care plan for

the person and this is stored in their IT system if they have one but some deployment sites still use

paper records in their community rehabilitation teams. Pharmacy records will also be kept

separately. Third sector organisations who are commissioned to provide specific services which

form part of the care pathway usually have a basic client database but most of the information

communication is undertaken by paper and fax.

In the SmartCare Project all aspects of the care plan will be entered and updated on the one

system. All relevant caregivers will have access to the care plan and can input and adjust as



required. A role-based access model will be adopted to ensure that the right people receive and

have access to the right elements of the person’s SmartCare record.


Across the deployment site in Scotland there is a range of telecare and telemonitoring already in

place but there is no consistent provision.

The SmartCare service will provide a range of telecare and telemonitoring services in line with the

different levels of risk in relation to falls prevention and any associated chronic conditions such as

COPD, heart failure and diabetes.

Integrated documentation of home care provided/self-care measures

At present there are very limited examples of integrated documentation. The Community

rehabilitation and enablement services are being developed across the partnership sites and good

examples of integrated paper care plans can be evidenced. Integrated ICT systems within an

organisation can be evidenced, eg the out of hours services have access to ICT systems and in an

emergency can access the full summary health history and up to date position with the person.

Protocols are in place to alert the out of hours service to the day’s events if there is a risk of

continued activity.

The SmartCare service will establish an integrated care plan for fallers and falls prevention which

the service user will have access to as well as practitioners. A single ICT system will be agreed at

each deployment site for the use of falls pathway planning and monitoring.

Control re-assessment/review

As with the assessment, co-ordination an integrated documentation, there is currently no consistent

approach across the Scottish deployment site in relation to monitoring and re-assessing the person

and therefore no formal information recording process.

Within SmartCare, the system will include the ongoing monitoring of a person’s progress in reducing

their level of risk and agreed re-assessment dates recorded in the integrated care plan.

Re- admission to hospital

Currently, if a person is re-admitted to hospital either by their GP or as an emergency, a summary

of their health record will be available in the hospital. This summary record also include some key

information in relation to a person’s social environment and wellbeing but it is not comprehensive.

Within SmartCare, the integrated care record will be available for hospital staff to access on re-

admission and they will be able to update it if necessary following a re-assessment of home care

needs.

Exit point

At present, communication of information regarding the completion of a care plan which requires

no further intervention will vary. For example, the completion of physio intervention which has

been prescribed by the GP will end with a final summary being sent to the GP in writing. The

completion of the Home Care service will not be sent to the GP but it may be communicated to the

community rehab team by phone. So the position is variable in the main and a co-ordinated IT

system is not used.

In the SmartCare Service the outcomes of all interventions will be recorded and a follow-up

date/review scheduled if required and recorded in the system. A caregiver will be designated to

complete any follow up/review visit.



3.4 Friuli Venezzia Giulia

3.4.1 Friuli Venezzia Giulia – Long-Term Home Care Support

Figure 22: ICP-LTCare: Current ICT Infrastructure & Systems –Friuli Venezzia Giulia

FVG – Current ICT Infrastructure & Systems


Assessment InfoMultidisciplinaryEvaluation Unitassessment (HC,SC, GP and other

actors) Repositoryon pts’data/G2,

paper/ERCommunication

to District(PUA) by GP, IC,

family (paper fax,phone or direct

contact)

Consent

Care PlanFinal multidisci-

plinary assessment(Case Coordinator,

GP, SW, etc).Valgraf question-

naire on paper, onGENESIS - ER system)

Repository onpts’data, G2 clinico

Care Co-ordination

Provided by CaseManager (nurseor social workeror other actors)

according tomultidisciplinarycare plan underGP supervision

Interventions &Services Info -

HealthcaremanagementCaseload

(Paper, phone,e-mail, repository G2)

Discharge andReferral Info

Hospitaldischarge

pathway (paper,ER-G2, repository

of pats’data)

Interventions &Services Info - Socialcare management

Caseload(Paper, phone,

e-mail)


Telehealth/-caremanagement

Caseload(Phone, e-mail, paper)

Self-Care InfoHome social/ health

service (telecare)through external call-

center (phone)


Services InfoHC and SC record

– paper and ER(G2, Cardionet),

Repository ofpts’data

Review andReassessment Info

Multidisciplinaryreassessment (Case

coordinator, GP, SW,etc). Valgraf

questionnaire onGENESIS- ER (G2,

Cardionet) Repositoryon pts’data

Admission InfoActivated from

GP/specialist/callcenter (telecare).

(Paper, repository ofpats’data, ER- G2,

Cardionet-, phone)


Multidisciplinaryteam (Paper, ER-G2, repository ofpts’data) Recordstays in District’s

and GP’Sarchives



Figure 23: ICP-LTCare: SmartCare ICT Infrastructure & Systems –Friuli Venezzia Giulia

FVG – SmartCare ICT Infrastructure & Systems


Assessment InfoDistrict LAN /

Paper filingSystem

District LAN /Paper filing

System EnrolmentSmartCare ICT

integratedplatform

(adsl/gprs/umts,etc)

Care PlanSmartCare ICT

integrated platform(adsl/gprs/umts,

etc)

CareCo-ordination

SmartCare ICTintegratedplatform


HealthcareInterventions &

Services InfoSmartCare ICT

integrated platform(adsl/gprs/umts, etc)



System

Social careInterventions and



Self-Care InfoSmartCare ICT


Integrated Caremanagement

Telehealth/-care InfoSmartCare ICT


CombinedInterventions and


integratedplatform



SmartCare ICTintegrated platform


Admission InfoSmartCare ICT

integratedplatform




System

Entry point

Currently, a patient with a chronic condition such as heart failure, COPD, diabetes etc., may be

referred by their GP, informal carer, family member to the Punto Unico di Accesso – One Access

Point (PUA). The referral information is paper-based and often faxed.



The PUA multi-disciplinary team will carry out a preliminary assessment on paper and this forms the

basis of a meeting of the Multi-dimensional Evaluation Unit (MEU) which includes a nurse, social

worker, GP, District physician, caregiver etc.

SmartCare will enable the preliminary assessment to be completed electronically for the MEU team

to use to aid their decision-making.


If following the multi-disciplinary assessment the patient is identified as suitable for SmartCare

consent would be sought. The consent, if given, will be entered into the SmartCare platform.


The Case Manager/Care Co-ordinator appointed by the MEU will complete the ValGraf assessment

form and draw up a tailor-made patient home care plan. The information on this ValGraf form is

subsequently entered into the GENESIS (regional ER) system and then can be seen by the District

multi-disciplinary team and hospital if necessary.

In SmartCare the ValGraf assessment would be shared in real-time with all the participating actors

including the patient and relatives if permitted. This will enable the home care plan to be more

easily tailored to an individual patient’s needs. If telemonitoring/telecare is included in the home



care plan, the relevant patient details will be added to the SmartCare platform and the patient and

any approved informal carers given information on how to access the platform from home. A

request via the SmartCare system would be sent to the dedicated telemonitoring/telecare team

who will set up the devices in the patient’s home. This activity will take place within 21 days from

enrolment and both patients and relatives/informal carers will be trained in using the platform.


Information contained in the ValGraf form is reviewed by the multi-disciplinary team and a case

manager/care co-ordinator is allocated. This person regularly updates the ValGraf during District

meetings and/or by phone or mail to meet the changing needs of the patient.

In addition to the above, within SmartCare, once any telemonitoring/telecare devices are set up in

the patient’s home they, together with their informal carer network will also be able to play an

active and interactive role with the multi-disciplinary team and the necessary revisions to the initial

care plan updated within the SmartCare platform and implemented.


Social care provision will be delivered in accordance with the home care plan and the information

will be recorded in the paper record held by the nurse. Regular communication will be maintained

with social workers, family and volunteers in relation to the wider social wellbeing needs of the

individual patient.

SmartCare will enable all those social care staff with the appropriate role-based access rights to

view and update the patient’s SmartCare record in line with their care provision and the needs of

the


Health care provision will be delivered in accordance with the home care plan and the information

will be recorded in the paper record held by the nurse and the regional repository (G2). Regular

communication will be maintained with social workers, family and volunteers in relation to the

wider social wellbeing needs of the individual patient or changes in their health care needs.

SmartCare will enable all those health care staff with the appropriate role-based access rights to


the patient.


The third sector is not usually part of the initial multi-disciplinary team assessment but may be

brought in to support the patient as a result of any review of the home care plan or re-assessment.

The third sector workers’ care delivery is recorded in their own paper diaries and the paper record

in the patient’s home.

With the appropriate permissions, third sector caregivers will be able to participate in the

SmartCare platform although the exact nature of their permissions, e.g. updating the record, has

yet to be agreed.


There is a call centre currently that provides a telecare service to residents and this will be

enhanced to include telemonitoring within SmartCare. Currently, if deemed necessary by the

GP/Case Manager telecare devices, including medication reminders, are installed to enable people



to remain independent in their own homes. Should an alarm be activated, the call-centre will

notify the patient, his/her caregivers, and if necessary, the emergency services and Case Manager.

The telemonitoring devices implemented as part of SmartCare will be aligned to the individual’s

health and social care needs and all caregivers will be able to access the uploaded information

through the SmartCare platform according to their pre-defined privileges. The health remote

monitoring of vital parameters such as Blood Pressure, Heart Rate, weight, Oxygen saturations etc.

will be undertaken daily with appropriate action being initiated in the event of an alert being

generated. Any information relating to home visits required by the health and social care team as a

result of an alert will be entered into the SmartCare system by the caregiver whilst in the patient’s

home and available to view for those with appropriate permissions.


Currently, the multi-disciplinary team has a mix of electronic records and paper-based information

on which to deliver its services. No real-time information on a patient’s self-care is currently

available.

SmartCare will provide a comprehensive and integrated care record for patients with complex needs

with all caregivers, the patient themselves and their relatives, access if they meet the permissions

agreed. This will include real-time information on the patient’s self-care measurements.


Currently, the Case Manager/Care Co-ordinator will communicate regularly with the multi-

disciplinary team members and together they will monitor and re-assess the patient’s health and

social care needs. The Case Manager will activate different caregivers should unmet or urgent

needs arise and this could include services from the third sector.

SmartCare will provide a real-time picture of the patient’s health and social care status and the

enabled additional services care and support to be activated ideally before a crisis situation

develops. Any changes to the home care plan will be recorded in SmartCare and the Regional

Repository (G2) system. A video conference between those actors involved in a patient’s care could

be held if needed.

Temporary admission to hospital or care home

If a GP or other care provider with the approval of the GP, decides to admit a patient to hospital an

electronic referral will be sent to the hospital. If a patient needs to be admitted to a care home

temporarily, information on the patient will be prepared on paper and sent by fax to the care

home.

In SmartCare, if a patient needs to be admitted to hospital they will have access to the up-to-date

information on the patient in the SmartCare system as well as that contained in the G2 and

Cardionet records.

Exit point

Many patients will remain on this pathway until the die, choose not to receive the services, or go

into a care home permanently. However, all patients will dis-enrol from the SmartCare project

when it ends.



3.4.2 Friuli Venezzia Giulia – Discharge Pathway

Figure 24: ICP-Discharge: Current ICT Infrastructure & Systems –Friuli Venezzia Giulia

FVG – Current ICT Infrastructure & Systems


Assessment InfoPre-assessment by

District Nursethrough Hospital

record, paper andERDischarge from

hospitalimpending

Communicationto District

by paper fax andphone contact

Consent

Care PlanFinal multidisci-

plinary assessment(Case coordinator,

GP, SW, etc) byValgraf question-naire on paper,subsequently

recorded on GENESIS(ER system)

Care Co-ordination

Provided by CaseManager (nurse

and/or socialworker or otheractors) accordingto GP care plan

(paper)


Healthcare manage-ment, Caseload(Paper, phone,

e-mail, repository G2)


As above

Interventions &Services Info - Socialcare management

Caseload(Paper, phone,

e-mail)


Telehealth/-caremanagement

Caseload(Phone, e-mail, paper)

Self-Care InfoHome social/ health

service (telecare)through external call-

center (phone)


Services InfoHC and SC record

– paper and ER(G2, Cardionet),

Repository ofpts’data

Review andReassessment InfoHealthcare, social

care and GPpaper record

Valgrafquestionnaire on

GENESIS - ER

Admission InfoActivated from

GP/specialist/callcenter (telecare).

(Paper, repository ofpats’data, ER- G2,

Cardionet-, phone)

Discharge andReferral InfoPaper and ERRecord stay inDistrict’s andGP’s archives

Discharge InfoHospital

discharge letteron paper and

ER(G2, Cardionet)

Figure 25: ICP-Discharge: SmartCare ICT Infrastructure & Systems –Friuli Venezzia Giulia

FVG – SmartCare ICT Infrastructure & Systems


Assessment InfoHospital and/or


SystemCommunicationon impending

dischargeto Hospital

and/or DistrictLAN / Paper filing

System

EnrolmentSmartCare ICT

integratedplatform


Care PlanSmartCare ICT

integrated platform(adsl/gprs/umts,

etc)

Care Co-ordination

SmartCare ICTintegratedplatform


HealthcareInterventions &



Discharge andReferral InfoDistrict LAN /

Paper filingSystem

Social careInterventions and



Self-Care InfoSmartCare ICT


Integrated Caremanagement

Telehealth/-care InfoSmartCare ICT


CombinedInterventions and


integratedplatform



SmartCare ICTintegrated platform


Admission InfoHospital and/or


System

Discharge andReferral InfoDistrict LAN /

Paper filingSystem

Entry point

Currently, if a patient is admitted to hospital the hospital records information in the G2 Clinico and

Cardionet systems and alerts the District about the admission through a paper home care activation



form sent by fax. This form, as well as notifying the District of a patient’s admission also requests

the involvement of the District Nurse to plan a ‘protected discharge’



A District Nurse visits the hospital within 72 hours to meet the patient and his/her relatives and

hospital staff to undertake an assessment to determine what care will be needed on discharge. The

assessment includes the patient’s clinical and psycho-social needs. At present, only partially

integrated data records are available on the regional repository (G2 Clinico and Cardionet) which

can be accessed by the hospital and District health workers. The assessment information is shared

within the District with the elderly patients’ assessment unit (UVA) which is a multi-disciplinary

team consisting of a GP, social worker, district physician specialist, psychologist, district nurses etc.

This team provides the relevant healthcare services upon the patient’s discharge.

The above process will also be followed within SmartCare.


If following the multi-disciplinary assessment the patient is identified as suitable for SmartCare

consent would be sought. The consent, if given, will be entered into the SmartCare platform.


When a patient is ready for discharge the District Case Co-ordinator (District Nurse or other MDT

member) will draw up a home care plan and complete a preliminary ValGraf multi-disciplinary,

longitudinal assessment and evaluation form. This paper form is subsequently recorded on the

GENESIS (regional ER) system. The information is then shared with the District multi-disciplinary

team.

In SmartCare the ValGraf assessment would be shared in real-time with all the participating actors.

This will enable the home care plan to be more easily tailored to an individual patient’s needs. The

relevant patient details for the telemonitoring/telecare will be added to the SmartCare platform

and the patient and any approved informal carers given information on who to access the platform

from home. A request via the SmartCare system would be sent to the dedicated

telemonitoring/telecare team who will set up the devices in the patient’s home. This activity will

take place within 7 days from enrolment and both patients and relatives/informal carers will be

trained in using the platform.


When the patient is discharged currently, a discharge letter is provided by the hospital in paper and

electronic form through the Regional Repository, G2 Clinico and Cardionet systems. Upon arrival at

home the patient usually has any equipment that was requested following the multi-disciplinary

assessment lead by the District Nurse.

This process will be the same within SmartCare unless telemonitoring/telecare devices are included

in the home care plan. If this is the case, information relating to the discharge will also be sent to

that team to arrange device installation and training.


Information contained in the ValGraf form is reviewed by the multi-disciplinary team and a case

manager/care co-ordinator is allocated. This person regularly updates the ValGraf during District

meetings and/or by phone or mail to meet the changing needs of the patient.



In addition to the above, within SmartCare, once any telemonitoring/telecare devices are set up in

the patient’s home they, together with their informal carer network will also be able to play an

active and interactive role with the multi-disciplinary team and the necessary revisions to the initial

care plan updated within the SmartCare platform and implemented.


Social care provision will be delivered in accordance with the home care plan and the information



individual patient.

SmartCare will enable all those social care staff with the appropriate role-based access rights to


the


Health care provision will be delivered in accordance with the home care plan and the information



individual patient or changes in their health care needs.

SmartCare will enable all those health care staff with the appropriate role-based access rights to


the patient.


The third sector is not usually part of the initial multi-disciplinary team assessment but may be

brought in to support the patient as a result of any review of the home care plan or re-assessment.

With the appropriate permissions, third sector caregivers will be able to participate in the

SmartCare platform although the exact nature of their permissions, e.g., updating the record, has

yet to be agreed.


There is a call centre currently that provides a telecare service to residents and this will be

enhanced to include telemonitoring within SmartCare. Currently, if deemed necessary by the

GP/Case Manager telecare devices, including medication reminders, are installed to enable people

to remain independent in their own homes. Should an alarm be activated, the call-centre will

notify the patient, his/her caregivers, and if necessary, the emergency services and Case Manager.

The telemonitoring devices implemented as part of SmartCare will be aligned to the individual’s

health and social care needs and all caregivers will be able to access the uploaded information

through the SmartCare platform according to their pre-defined privileges. The health remote

monitoring of vital parameters such as Blood Pressure, Heart Rate, weight, Oxygen saturations etc.

will be undertaken daily with appropriate action being initiated in the event of an alert being

generated. Any information relating to home visits required by the health and social care team as a

result of an alert will be entered into the SmartCare system by the caregiver whilst in the patient’s

home and available to view for those with appropriate permissions.




Currently, the multi-disciplinary team has a mix of electronic records and paper-based information

on which to deliver its services. No real-time information on a patient’s self-care is currently

available.

SmartCare will provide a comprehensive and integrated care record for patients with complex needs

with all caregivers, the patient themselves and their relatives, access if they meet the permissions

agreed. This will include real-time information on the patient’s self-care measurements.


Currently, the Case Manager/Care Co-ordinator will communicate regularly with the multi-

disciplinary team members and together they will monitor and re-assess the patient’s health and

social care needs. The Case Manager will activate different caregivers should unmet or urgent

needs arise and this could include services from the third sector.

SmartCare will provide a real-time picture of the patient’s health and social care status and the

enabled additional services care and support to be activated ideally before a crisis situation

develops. Any changes to the home care plan will be recorded in SmartCare and the Regional

Repository system.

Re-admission

If a GP decides to re-admit a patient to hospital an electronic referral will be sent to the hospital.

In SmartCare, the only difference in the process will be that the patient is already entered into the

Shared Care platform and the involved caregivers will have the electronic referral if a GP has

admitted the patient, together with the historic data to help inform their decision making. If the

patient is admitted as an emergency, the information in the Shared Care record will be available to

the caregivers.

Exit point

The patient will probably remain in the Shared Care platform on the Long-Term Care at Home

pathway until they are deceased or wishes to be taken out of the system.



4 Towards SmartCare Architecture: Technical

Mapping

This section presents an overview of existing efforts at EU and global level in standards, standards

guidelines and profiles containing standards development which have relevance to the SmartCare

functional blocks as described in section 2. This initial technical mapping will provide the basis for

further architecture development final outcomes of which will be reported in the forthcoming D3.2.

4.1 Outputs from Functional Blocks

Enrolment and consent

As per Table 1, the enrolment and consent functional block has an output of a discharge summary

and recommendations for care. One possible contribution to the SmartCare project would be

identification of useful elements of a standard data set for a combined care plan. In the EU, epSOS

has identified a common patient (discharge) summary

(D3.2.2_Final_Definition_Functional_Service_Req_Patient_Summary) which has the following high

level elements (details are in Table 5 of epSOS referenced document):

Personal information

Contact information

Insurance information

Patient Clinical information to include: alerts, history of past illness, medical problems,medication summary, social history, pregnancy history, physical findings, and diagnostictests.

The epSOS minimal patient summary set does not include a functional assessment which would be a

critical part of being able to provide a social care plan.

A possible addition to the patient discharge summary data set from epSOS would be the following

functional assessment data elements (as per: HL7 Implementation Guide for CDA R2 CRS R2

Discharge Summary - draft, also,

http://www.cdatools.org/infocenter/index.jsp?topic=%2Forg.openhealthtools.mdht.uml.cda.ccd.do

c%2Fclasses%2FFunctionalStatusSection.html)

Ambulatory ability

Mental status or competency: cognitive status, affective status, neurobehavioral symptomsassociated with dementia, facultative

Activities of Daily Living (ADLs), including bathing, dressing, feeding, grooming

Home / living situation having an effect on the health status of the patient

Ability to care for self

Social activity, including issues with social cognition, participation with friends andacquaintances other than family members

Occupation activity, including activities partly or directly related to working, housework orvolunteering, family and home responsibilities, or activities related to home and family

Communication ability, including issues with speech, writing, or cognition required forcommunication



Perception, including sight, hearing, taste, skin sensation, kinesthetic sense,proprioception, or balance

Other information may include the following:

Functional status

o Urinary or fecal incontinence

o Mobility/transfer

o Facultative: Walking speed, Timed «Up & Go», Berg score

Home support services

o Household help

o Help with meal preparation

o Help with errands

o Meals on wheels

o Accompaniment service

o Friendship visits

o Orderly support for personal hygiene

o Other

Services for natural caregivers

o Respite

o Information/counselling service

o Psychosocial services

o Support groups

o Other

Technical support

o Orthotics or prosthetics

o Walker

o Cane

o Wheelchair

o Special equipment (bars...)

Another possible overview of a minimum data set is derived from NHS’ “Developing Standards for

Healthcare and Social Records, Report of the Joint Working Group”. In section 5.4, starting on page

44, is a recommended minimum data set listed (as below).

Patient details

o Surname, forename, known as, date of birth, gender, NHS number, patient address,patient telephone number

o Conditions (if known and/or appropriate)

o Current Medications (complete list, prescribed, OTC, herbal, dressings, devices etc)

Name

Dose

Frequency

Formulation (tablets, drops, liquid, Special preparation etc)



Route of administration

Storage where relevant

o Medication changes

o Medication started – why, for how long, who reviews and when

o Medication stopped – why

o Allergies, adverse reactions or contraindications

o Additional relevant information/special instructions

o Additional information supplied to the patient e.g. how long a new medicine maytake to work

o Additional information about specific medicines e.g. preservative free required,brand names where bioavailability issues

o Adherence support required (e.g. compliance aids, prompts, packaging etc)

o Information should be signed and dated by the healthcare professional transferringdetails of the medication.

Contact details of a named individual should be available to the healthcare professionalreceiving the patient

The output of this functional block would be an integrated plan which takes into account the

SmartCare discharge summary document and identifying those services which need to be provided

either at the patient home or through a remote monitoring mechanism. HL7 CDA R2 does have a

section which identifies a care plan. By adding the functional assessment and other social care

elements, and integrated care plan template could be developed.

Onsite provision of care

The input of this functional block requires a scheduling and appointment management system along

with access to the care plan and a documentation mechanism for assessment of the care. Again,

the underlying discharge summary document and care plan drive this function, with a connecting

function of scheduling the care.

Remote provision of care

The input of this functional block is the discharge summary and care plan as in 2.7.3. Additionally,

within this functional block is the implied provision of a telehealth/telecare system. The

healthcare requirements for a specific disease or status will drive the basic vital parameters being

monitored. Here there would also be remote monitoring of any environment parameters, the

delivery of educational or training information, and/or reminders for self-care. Another activity of

this functional block would be a possible “real-time” virtual engagement with a telehealth center or

even a care provider. The output of this functional block would be the data items measured or

delivered through the telehealth technical system. Ideally these would be in a standard format for

interfacing to other systems.

Documentation of care

Ideally the output of this function would be concomitant with the actual provision of care.

Assessment of care

As for the documentation function, this function should ideally be concomitant with the provision of

the care as well as post provision of care. Certain triggers of the response to the care during the

assessment phase would then determine whether or not the care recipient should exit the pilot.



Exit from pilot

This would receive as inputs the assessment and triggers which determined the care recipient

should exit SmartCare.

4.2 Standards, Standards Guidelines or Profiles Containing

Standards that can be used for SmartCare System

IHE - Integrating the Healthcare Enterprise

IHE is a global initiative involving more than 300 stakeholders (healthcare professional associations,

industry, health authorities, etc.). It is the worldwide reference organisation for the

interoperability of healthcare information systems and devices. IHE promotes the coordinated use of

established standards such as DICOM (Digital Imaging and Communications in Medicine) and HL7

(Health Level 7) to address specific clinical needs in support of optimal patient care. With strong

involvement from users, IHE has been testing the interoperability of HIT systems for more than a

decade. The Connect-a-thon is the healthcare IT industry largest interoperability testing event.

More than 250 vendors worldwide have implemented and tested products with IHE capabilities.

In the case of SmartCare, the following IHE profiles could apply to the within and at interfaces of

the different functional blocks. The specific functional blocks where these IHE profiles can be used

is noted in the table above. Note that IHE profiles tend to be telecommunications protocol

agnostic, so therefore, instead relying upon the telecommunications industry and market to define

the lower layer protocols/standards. Each of the profiles represents an interface in which the

actors are defined and a standard or standards identified for that specific interface and/or

transaction.

IHE is divided into domains which are responsible for work on the different profiles. Listed below

are the applicable profiles underneath each applicable domain. The dedicated Wiki web site

(http://wiki.ihe.net/index.php?title=Profiles) provides a complete listing of all profiles and the

underlying standards.

ICT Infrastructure (IHE ITI):

(BPPC] Basic Patient Privacy Consents method for recording a patient's privacy consentacknowledgement to be used for enforcing basic privacy appropriate to the use.

[XCA] Cross-Community Access allows to query and retrieve patient electronic healthrecords held by other communities.

[XDM] Cross-enterprise Document Media Interchange transfers documents and metadatausing CDs, USB memory, or email attachments.

[XDR] Cross-enterprise Document Reliable Interchange exchanges health documentsbetween health enterprises using a web-service based point-to-point push networkcommunication

[XDS] Cross Enterprise Document Sharing share and discover electronic health recorddocuments between healthcare enterprises, physician offices, clinics, acute care in-patient facilities and personal health records.

[XDS-SD] Cross-enterprise Sharing of Scanned Documents enables electronic records tobe made from legacy paper, film, and other unstructured electronic documents.



[PDQ] Patient Demographics Query lets applications query by patient demographics forpatient identity from a central patient information server.

[PIX] Patient Identifier Cross Referencing lets applications query for patient identitycross-references between hospitals, sites, health information exchange networks, etc.

[PDQv3] Patient Demographics Query HL7 v3 extends the Patient Demographics Queryprofile leveraging HL7 version 3.

[PIXv3] Patient Identifier Cross-Reference HL7 v3 extends the Patient Identifier Cross-Reference profile leveraging HL7 version 3.

Patient Care Coordination (IHE PCC):

[MS] Medical Summaries describes the content and format of Discharge Summaries andReferral Notes.

[XPHR] Exchange of Personal Health Record describes the content and format ofsummary information extracted from a PHR system for import into an EHR system, andvice versa.

[CM] Care Management exchanges information to manage care for specific conditions.(this Profile is not in final format, however, underlying standards identified in theprofile are final).

Patient Care Device (IHE PCD):

[DEC] Device Enterprise Communication transmits information from medical devices atthe point of care to enterprise applications.

[RTM] Rosetta Terminology Mapping harmonizes the use of existing nomenclature termsdefined by the ISO/IEEE 11073-10101 nomenclature standard, it is required to be used inall PCD transactions (Note: RTM is a constrained value set).

[ACM] Alert Communication Management communicates alerts (alarms - physiological ortechnical, or advisories), ensuring the right alert with the right priority gets to the rightindividuals with the right content.

The European project epSOS, also developed standards patient summaries and as per section 2.7.1

could provide the minimum patient summary data set which when combined with a functional and

social assessment could be the basis for a SmartCare patient summary.

Continua Health Alliance Guidelines

The Continua Health Alliance, founded in 2006, now with more than 230 member companies around

the world, is dedicated to establishing a system of interoperable personal health solutions.

Extending these solutions into the home fosters independence, empowers individuals and provides

the opportunity for truly personalised health and wellness management. The strongest value of

Continua is the Continua Certified Logo program, signifying that the product is interoperable with

any other Continua-certified products. Certification comes with rigorous independent testing to the

selected Continua standards. The main thrust of Continua currently is the personal telehealth

arena, which includes chronic condition management, health and wellness, and ageing

independently.

Products made under Continua Health Alliance guidelines provide consumers with increased

assurance of interoperability between devices, enabling them to more easily share information with

caregivers and service providers.

Below is a system architecture diagram as depicted by Continua with the relevant standards as

applied to the interfaces. Continua further constrains the standards so that vendors can be

independently certified to meet the Continua guidelines with an ultimate goal of interoperable



‘plug and play’ products for the market. Continua does specify underlying telecommunication

standards as that is required to reach system ‘plug and play’ interoperability capability.

The objects in the Continua architecture are personal devices (tiny area network (TAN) / personal

area network (PAN) / local area network (LAN)), application hosting devices (AHD), wide area

network (WAN) devices and health reporting network (HRN) devices.

Note that the HRN interface contains the same standards as those promulgated by IHE-DEC.

Figure 26: Continua E2E architecture

The underlying standards specified in the Continua guidelines are:

Device Data – IEEE 11073 20601 and PHD standards

Device connectivity (wired) - USB

Device based connectivity (wireless)– ZigBee, Bluetooth and Bluetooth Low Energy (LE),and Near Field Communication (NFC)

WAN based connectivity (wireless) – WiFi (IEEE 802.1xx) and GSM

WAN/HRN based– messaging – WorldWideWeb Consortium (W3C), Health Level 7 (HL7),and IHE PCD-01 DEC

Another partner in these efforts is ETSI, the European Telecommunications Standards Institute. The

most outstanding examples of globally successful communication technologies that have been



standardized in ETSI (or ETSI partnership projects) are GSM (mobile telephony), UMTS (Universal

Mobile Telecommunications System, 3rd generation mobile) and DECT (Digital Enhanced Cordless

Telecommunications). The key factor in their success was a very high level of interoperability. To

achieve that, the conformance test specifications were standardized in ETSI with a high level of

rigor and precision as well as high level of transparency and commitment of technology

stakeholders. This effort was as a rule supported in many different ways by policy makers

(regulation, co-funding etc.) which was an important additional catalyst.

As of the publication of this document, the Smart Home industry has not settled on a set of data or

messaging standards across the different solutions set available. As in most other industries, they

do rely upon the underlying telecommunications and transmission standards (TCP/IP, WiFi,

BlueTooth, ZigBee, etc). In fact, on 30 October 2013, it was announced that four of the largest IT

and home appliances companies (ABB, Bosch, Cisco and LG) will join forces for producing a common

standard for smart homes monitoring and this is only the beginning as more and more companies

will be willing to contribute to the definition of a common framework of development eagerly

waiting for the market to take off. Lack of standardization is generally considered as a market

inhibitor since solutions lack also reusability and more often scalability. It was only the networking

aspect of smart home concept that at least providers showed some consistency hence rendering

Zigbee (IEEE802.15.4) as an industry standard due to its very low power consumption, the most

essential characteristic in the sensors’ micro-world.

As of the publication of this document, there are no established standards for social care records.

Nevertheless there is work internationally in different regions in identifying what would be needed

to establish these standards as well an integrated care record. One effort is by the NHS as

identified in section 2.7.1 for the minimum data set in the discharge summary. Another effort is

being developed by the HL7 Care Coordination Capabilities workgroup in identifying standard

service required for a care plan. This effort is detailed in the next section.

4.3 Architecture Considerations for SmartCare Functional Blocks

The diverse and integrative nature of the functions provided within SmartCare lends themselves to

the use of a Service Oriented Architecture (SOA). SOA is based on the concept of a service. Each

service that makes up an SOA application is designed to perform one activity. As in epSOS, “SOA is a

relevant architectural style: it can decouple interface and implementation as well as avoid

dependence or future rigidity. In an SOA solution, the only characteristic of a service that a

requesting application needs to know about is the “public” interface.” SOA also defines how to

integrate widely disparate applications for a Web-based environment and uses multiple

implementation platforms. Rather than defining an application programming interface (API), SOA

defines the interface in terms of protocols and functionality.

A possible template for a SmartCare SOA is described by the HL7 Wiki for Care Coordination

Capabilities

(http://wiki.hl7.org/index.php?title=Care_Coordination_Capabilities). It is based on the HL7 SOA

Healthcare Services Support Program (HSSP) Service Functional Model specification.

Listed below are proposed service modules for Care Coordination Capabilities as per the Wiki. Each

of these would be a service that could be applied across the SmartCare system. Each service has

specific actions that are associated with the service capability.

Plan Capability Set

Find Plan



Find Plan Template

Create Plan

Associate Plans

Change Plan

Close Plan

Read Plan

Share Plan

Synchronize Plan

Publish Plan Template

Manage Supportive Plan Content Capability Set

Associate Supportive Content

Dissociate Supportive Content

Mark Plan Items for Action Capability Set

Mark Plan Item

Retrieve Marking Group

Care Team Capability Set

Find Person

Invite Collaboration Participants

Respond to Collaboration Invitation

Add Care Team Member

Remove Care Team Member

Find Collaborator Relationships

Care Team Conversation Capability Set

Care Team Conversation Thread

Invite New Conversation Participants

Respond to Conversation Invitation

Identify Conversation Thread Participants

Participant Availability Capability Set

Indicate Availability for Collaboration

Find Collaborator Availability

Patient Observations Capability Set

Capture Patient Observations

Associate Observations

Edit Observations

Retrieve Observations

Identify Health Assessment Scales

Clinical Appropriateness Capability



Care Plan Action Capability Set

Propose Action

Start Action

Suspend Action

Resume Action

Cancel Action

Complete Action

Find Available Resources

Check Resource Availability

Allocate Resource

Care Review Capability Set

Acceptance Review

Activity Outcome Review

Goal Review

Plan Review

Consolidation/Reconciliation Capability Set

Consolidate Plans Capability

Get Reconciliation Work List Capability

Documentation Template for Capability Details

Mapping of HL7 Care Coordination Capabilities Services to SmartCare

The table below depicts a preliminary mapping of the service modules described above to the

SmartCare functional blocks. There is a lack of service modules available for the enrolment and

consent and pilot exit functional blocks as the Care Coordination Capability service module map is

aligned with the planning and delivery of care and not necessarily entry/exit into a pilot program.

Each of the service modules associated with the SmartCare Functional Blocks would either include

the full complement of sub-actions in the module or only those actions depicted in parentheses

after the service module specification. There is a commonality in the service module use across

the functional blocks, however, there are exceptions which are based on the users and activities

associated with each of the SmartCare functional blocks.

The Plan Capability Set is common to all of the SmartCare Functional blocks, so could theoretically

be a base capability platform or service from which all of the other services would be integrated.



Table 3: Functional Blocks: Mapping to HL7 Care Coordination Capabilities Services

SmartCare Functional Block Service Module

Enrollment and Consent

Care Plan Plan Capability Set; Care Plan Action Capability Set;Care Review Capability Set;Consolidation/Reconciliation Capability Set; ManageSupportive Plan Capability Set; Clinical AppropriatenessCapability Set; Care Team Capability Set;Consolidation/Reconciliation Capability Set

On site provision of care Plan Capability Set (read/share plan); Care Plan ActionCapability Set; Care Team Capability Set; Care TeamConversation Availability Set; Participant AvailabilityCapability Set; Care Review Capability Set

Remote provision of care Plan Capability Set (read/share plan);Care Plan ActionCapability Set; Care Team Conversation AvailabilitySet; Participant Availability Capability Set; PatientObservation Capability Set; Care Review Capability Set

Documentation of care Plan Capability Set; Manage Supportive Plan ContentCapability Set; Care Review Capability Set; PatientObservation Capability Set; Documentation Templatefor Capability Details

Assessment of care Plan Capability Set; Manage Supportive Plan ContentCapability Set; Care Review Capability Set; PatientObservation Capability Set; Documentation Templatefor Capability Details

Exit from Pilot



5 Summary, Conclusions and Next Steps

It is clear from working through the three different layers making up the information,

communication and technologies (ICT) that all the first wave deployment sites will have different

starting points in relation to:

Their country’s or region’s configuration of health and social care services and theextent to which this can be changed at a local level

The extent to which information is currently recorded and by whom

The legacy IT systems which will need to be incorporated into the SmartCare solution

The methods of communicating and sharing relevant information amongst a wide rangeof caregivers, the patient and any informal/family members

The involvement of the different caregivers, the patient and any informal/familymembers in delivering and supporting the activities within the SmartCare ICT enabledpathways

The range of ICT enabled services which will be included in the SmartCare pathways

As expected, the main gaps across all of the initial pilot sites deals with the integration of services

delivered by different entities as well as common access to information gathered by those entities.

Additionally, the provisions on home care across disciplines and integration of that information via

electronic and other means needs to be developed in most of the pilots sites. With regard to

electronic health records, there is a requirement to add information from the social care and

informal care givers as well as integrate or consolidate the telemonitoring input. Moreover,

incorporating the patient or care recipient information is not common from before. Lastly, the pilot

sites will integrate the legacy technology elements with new information entry sources, so a

modular approach with defined interfaces and the use of service oriented architecture will be

recommended and promulgated moving forward.

The SmartCare pilot regions are currently working with their integrated care teams (including

technical experts) to consolidate the types of functionality and data which will be delivered and

shared to implementing the SmartCare pathways.

The next steps in the development of this work package will be to taking forward the gap analysis

for each deployment site.

Outcomes will be fed into the final version of the service specification and common architecture –

to be reported in D3.2, and into WP4 for prototype development and testing.

SmartCare D3.1 Pilot Level Service Specification - … · The SmartCare project is co-funded by the...

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