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Figure 2 | Journal of Translational Medicine

Figure 2

From: Synergy-COPD: a systems approach for understanding and managing chronic diseases

Figure 2

Workflow for an Integrated Care Service (ICS) management and execution. The patient is allocated into an ICS defined as a set of well standardized tasks to be carried out on the basis of his/her health condition and social circumstances to achieve target objectives aligned with the comprehensive treatment plan. Two differential ICS characteristics, as compared to usual care, are the patient-centered approach and the longitudinal nature of the interventions which length depends on the type of ICS. The corresponding ICS template is used as a library of resources for the correct customization and execution of the ICS workflow. Integration with corporate Electronic Health Record (EHR) allows instant access to required patient information for case identification and evaluation, avoid data duplicity and preserve the current corporate clinical data chain of custody. Follow-up and discharge reports can also be sent to the corporate EHR to keep trace of the ICS execution as part of the patient clinical episodes.

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