Illustrative scenario · Health systems
A between-visit layer for a chronic-disease population
A health system runs a chronic-care program for patients with several long-term conditions.
Challenge
The scenario's data and workflow challenges
- Records were rich at encounters and silent in between.
- The team had no way to see which patients were drifting.
Data sources
Data sources in the illustrative workflow
- EHR records
- Home devices
- Structured PROs
- Lifestyle check-ins
Approach
The proposed collection and integration approach
Condition profiles
Patients joined with a profile matched to their conditions.
Trajectories
Clinicians saw between-visit trends in their workflow.
Research asset
Consented, aggregated data supported research partnerships.
Workflow
- EHR link
- Enrollment
- Continuous data
- Clinician trajectories
- Population insight
Outputs
Illustrative outputs for each team
- Clinicians
- Trajectories inside the workflow
- Program leads
- Engagement by cohort
- Research office
- Consented aggregated datasets
Outcomes
Results, once confirmed
We only publish measured outcomes that have been confirmed and approved.
- Outcomes are reviewed with the program and published only after confirmation.
More scenarios
Related scenarios
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