Patient Centric Care Management with Patient Portal

Healthcare needs a paradigm shift from being expert-centric to becoming patient-centric in order to achieve better coordination of care, improved outcomes and reduced cost. Patient engagement is the key enabler to make this happen.

Payers and providers, globally, have recognised this need, and many have been adding patient engagement programs to their services in the past few years, in the form of web based personal health records (PHR) or patient portals. However, the success of most of these initiatives has not been encouraging, with poor take- up by patients or lack of improvement in outcomes. Even those PHRs that claim large usage are being used primarily to re-order medications, view appointments or communicate with providers through messaging.

At the heart of the problem lies the nature of the PHRs. Most PHRs are either stand-alone, which means that patients have to enter all their information themselves and get very little value from it, or tethered to a provider’s electronic medical record (EMR) so the patient information is incomplete, being limited to that available in that provider’s EMR system, requiring patients to access multiple providers’ patient portals. Patients want, but do not get a single view of all their relevant information as present in the diverse systems their providers may have.

CareVigilance, a population health management (PHM) system with integrated patient engagement tools, has been developed by AxSys using its Excelicare platform. CareVigilance connects the healthcare environment and enables care coordination by ensuring that the right information is available at the right time to the right person. It is based upon a health information exchange hub (HIE hub) and an aggregated clinical data repository that has the ability to construct a lifetime health record per patient from the information it collects, presenting the key items of data in an easy-to-read continuity of care document (CCD) summary. It has a smart algorithm-based engine that analyses patient information and generates alerts ensuring care is delivered to standards. It provides patients with technology to engage with professionals as well as keeping them informed of their compliance with care programs. All information stored within CareVigilance is available for analytics and can be used to further introduce efficiencies in the healthcare system.

Recognising that patients, providers and payers needed to be engaged across the continuum of care, AxSys architected the Excelicare platform as a smart hub capable of orchestrating care delivery in a patient centric manner. Combining patient engagement with PHM tools makes CareVigilance unique.


Using CareVigilance the health service can unlock the real potential of a PHR by using population health data to engage with the right patients at the right time. It’s aggregated clinical data repository and rules engine can drive personalised care interventions utilising evidence-based health rules, something that is known to motivate people at times when they are much more likely to act on their health. For example, individuals on a COPD care program receive timely alerts to complete a personalised self-assessment that feeds into CareVigilance which automatically adjusts their GOLD (Global Initiative for Obstructive Lung Disease) score. CareVigilance includes dashboards to monitor key metrics in near real-time and use pre-defined triggers to make the PHR data actionable at scale. Dashboards also help in the discovery of gaps in care and compliance of both providers and patients to the care protocols that have been implemented.

AxSys have always believed that personal and population health management must go together in order to build an effective person-centred health care system.

CareVigilance helps organisations achieve the triple aim of improving the experience of care, improving the health of populations and reducing the per capita costs of healthcare.