Table 2.

The requirements for the cloud-based health portal.

Shared cloud portal

Define a shared collaborative workspace, with secure access from actual health care team members and the patient/close relatives, based on regulations for privacy and security.

Implement cross-organisational access from the patient's electronic health record to all the involved systems (hospital, local doctor/GP, municipality home care services, and national health portals with relevant information and functions).

A customised workspace and user interface on all relevant platforms, also for mobile solutions.

Automatic back-end synchronizing of stored information to the relevant EHR systems (at the hospital, local doctor/GP, municipality home care services) for necessary medical documentation and activity log documentations.

Information flow functionalities

Integrated information flow, where all team members involved have immediate access to relevant real-time information and current patient status.

Real-time information of health care action plans and status of tasks, with two-way e-communication between team members and the patient.

Constant visualization in a dashboard of defined risk factors, risk stratification, and the progress.

Health care actions and support with visual indication of fulfilment and improvements according to a plan.

Automatic trigger of unexpected events or unnormal deviations according to a plan, based on triage algorithms.

Integration of electronic prescriptions to keep control of active medications, also integrated with a patient's medicine dispenser with programmed time intervals to monitor medication taken and with relevant warnings.

Patient involvement and support

Registration of «what I want my carers to know about me?» and «what matters to me?»

Integration of telemedicine functions with the patient's self-monitoring and recording of vital sign parameters with regular report on status based on disease-specific questionnaires and patient-reported outcomes reports.

Integration with implanted devices and sensors such as pacemakers and ICD systems that regularly report cardiac situations and arrhythmia events. Blood glucose sensors that monitor and regulate insulin therapy.

Integration with medical equipment used by the patient such as PAP/CPAP/sleep apnea assistance technology, home respiration equipment, and home dialysing equipment.

Implemented e-consultation functionalities with video solutions in order to facilitate virtual contacts and remote medical consultations.

Implement virtual rehabilitation plans and activities for the patient to self-manage and carry out defined activities for training and re-establish functions for active daily living.

Electronic messages and support for the patient in a user-friendly workspace with easy access to all relevant information and personal activity tasks.

Integration of mobile self-help and well-being third-party applications.

Teamwork support

Teamwork functionality with easy involvement of new team members for the particular patient depending on the actual situation and competence needed.

Task handling function, where a dedicated task can be assigned to a specific person for follow-up within a deadline, and a visual overview for all team members on the ongoing tasks with status.

The patient's own daily tasks and recordings of activity and medical measurements are automatically included in a visual dashboard showing the degree of self-management and improvements according to a plan.

Integration of telecare alarm systems and response centre services for necessary actions and follow-up on critical alarms and warnings.