This page is part of the Standard Personal Health Record (v1.0.0-ballot: STU1 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. . For a full list of available versions, see the Directory of published versions

Markus

Markus

Sports out-patient and home-based Cardiac Rehabilitation (CR) with rich data capture

ⓘ Contribute to this guide by helping translate the following patient journey into FHIR resources and refining the patient example! This narrative is a work in progress, and we have added Michael Ward as a temporary place holder to a patient with congestive heart failure. The .phr file needs updating to correspond to the following narrative. Pull requests encouraged.

Narrative History

Markus is a 57-year-old Austrian man who recently had a heart attack. His cardiovascular risk factors comprise: overweight, hypercholesterolemia, smoking, arterial hypertension, and a sedentary lifestyle as he does not engage in any type of sports or significant exercise. After his heart attack, he stayed in the hospital for 1.5 weeks and therefore completed phase 1 of Cardiac Rehabilitation (CR). He was then referred to a center-based cardiac rehabilitation program as an outpatient for phase 2. His initial assessment was performed by a staff physician at the Reha-Zentrum Salzburg, at the University Hospital Salzburg, Austria.

Before CR phase 2 initiation, the care team had access to Markus’ medical history and medications (via ELGA, the national EHR in Austria) to retrieve the medical indicators related to cardiac risk factors (blood pressure, lipids, blood glucose, etc.) and the disease underlying his myocardial infarction, i.e. coronary artery disease. The provider also conducted the initial assessment of Markus' exercise capacity, lifestyle risk factors (physical activity, diet, smoking, arterial hypertension, and alcohol), psychosocial health (depression and anxiety), and adiposity (waist circumference). With this initial assessment, Markus and his care team were able to identify the needs for the phase 2 of the CR program and agree on his personalized goals. In addition to the clinical goals for his cardiac health, Markus has several personal goals that motivate him to continue, including the desire to return to work, but also to get back to golfing with friends and to be able to keep up with his grandchildren. Phase 2 was successfully completed, but goals were not yet reached. So, it was decided to apply for phase 3 CR, which was granted by his pension plan. For CR phase 3, Markus and his physician collaboratively identified an activity prescription according to Markus’ preferences. It was also revealed that during phase 3 there will be an episode of 3-month home-based CR program. Several digital applications were suggested to Markus that could assist him during that phase. As he does have average digital skills, he is willing to commit to use such apps and avoid traveling to the clinic. He aims to control his cardiovascular risk factors (mainly high blood pressure and cholesterol) and increase his cardiovascular fitness to reduce the risk of disease progression and future cardiovascular events. Also, he is motivated to pursue further healthy behavior changes. Although Markus is not very engaged with technology, he finds a sense of satisfaction in using the smart CR app, recommended by his rehab team, to track his progress and communicate with his care team, and he is already using it during the initial phase 3 CR, in order to be well prepared for the home-based phase. The activity prescription calls for Markus to perform at least 150 minutes and even better 300 minutes of moderate exercise per week for 4-6 weeks, in addition to regularly logging his weight, blood pressure, and blood glucose. In case he wishes to exercise more intensively, exercise times of 75 minutes and even better 150 minutes per week would suffice. This seems like a lot of tracking for Markus, since he’s not been very involved in either his health or digital technology. However, his rehab team supported him in getting the CR app and related tools set up. At home, his daughter helped him coordinate the devices and make sure everything was working together.

The smart CR app enabled Markus to easily record his physical activity through his new smartwatch, log his weight, monitor and record his blood pressure (with the ability to link to a Bluetooth connected device and streamline blood pressure readings straight into the app), assess daily caloric intake and his dietary content of fat, saturated fat, sodium, and other nutrients in addition to eating habits. Tracking his diet has been the hardest for Markus and he is pretty sporadic about doing so. His wife and daughter also help him in tracking these activities, entering the measurements when needed or when it feels like too much for Markus. Also, Markus worked on improving his skills in using the CR app and other health apps.

On a weekly basis, all recorded data from Markus' smartwatch and CR app were transferred to his physician via passive data sharing. Markus had to enter his weight from the app connected to his digital scale (active sharing). The physician required all this data to assess Markus' risk factors during CR phase 2 (solicited). His clinician was able to assess Markus's risk factors weekly and make relevant decisions on the required intervention plan and/or education. For example, when Markus did not achieve the physical activity goals in one week, his rehab team was able to customize the activity plan for the following week to fulfill the activity target (perform at least 150-300 min a week of moderate-intensity or 75-150 min a week of vigorous-intensity aerobic physical activity or an equivalent combination thereof). In addition, the clinician was able to share educational material on sustaining healthy lifestyles with Markus when he noticed that he could not lose weight during the first weeks. Markus also received educational material that helped him in smoking cessation.

These data enabled Markus to successfully accomplish CR phase 3, especially during the COVID-19 lockdown, when he was unable to visit the cardiovascular clinic as regularly. Also, self-tracking, personalized goals, and shared decisions motivated Markus to sustain his behavior change towards a healthy, physically active lifestyle to prevent future attacks. Accordingly, Markus plans to use a CR self-referral tool also after CR phase 3, when he will engage independently in phase 4, i.e., lifelong secondary prevention.