- Partner self-managing adults and family caregivers with medical-home and primary-care providers and with chronic illness and disability specialists.
- Help consumers and family caregivers who have limited, sporadic, uncoordinated and unsatisfactory health care access due to lack of insurance or underinsurance.
- Automate planning, coordination, monitoring and refinement of cross-provider and cross-condition care plans.
- Support individualized evidence-based treatment plans that align generic disease-management guidelines and consumers' special needs and resources.
- Enable consumers, family caregivers and providers to observe expected and unexpected results of care plan milestones and engage in data-driven rather than speculative problem solving.
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- After subscribing to a Smart PHR™, the consumer picks one or more Life Agents that suits her needs (e.g., the Cancer Life Agent and the Fitness Life Agent).
- With more than one Life Agent, there is no duplicate data entry. Data entered into one Life Agent automatically populate the consumer's other Life Agents.
- The consumer grants specific Life Agent privileges to current and new users of her Smart PHR™. Users with read privileges may access the Life Agent at any time form any web-connected device without software downloads and at no charge to them.
- When authorized users access the Life Agent they see collapsed versions of all sections. Clicking on header links opens sections for detailed views.
- The patient background section of the Life Agent (including information usually requested on a doctor's waiting-room clipboard) is automatically populated from previous manual or automated entries in the consumer's Smart PHR™.
- An assessment section includes online versions of relevant diagnostic measures (e.g., an Activities of Daily Living checklist) and user-created links to relevant images, and documents.
- A treatment plan section guides specialist clinicians in the communication of relevant evidence-based intervention, referral, and follow-up milestones to consumers and to their non-specialist health and human service providers.
- An observation section guides self-managing consumers and family caregivers in use of cell phones for continuous observation of critical symptoms and side effects.
- Longitudinal graphs are continuous updated to show new observations and the relationship between observations and intervention milestones. Consumer-authorized providers have instant access to graphic displays for informed problem solving.
- A care coordination section guides activist family caregivers, case managers or medical home practice managers in delegating and monitoring referrals for diagnostic, intervention, and long-term care responsibilities.
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