Background: The Integrated Treatment Pathway Stroke Tyrol was introduced for the care of people after an acute stroke event and includes four phases: acute prehospital care, inpatient treatment, inpatient rehabilitation and ambulatory, outpatient rehabilitation. For the 4th phase, the ambulatory rehabilitation of patients after discharge, the ICT platform "StrokeNet Tyrol" was established.
Methods: Requirements and processes along the pathway and between the interdisciplinary team were taken into account for implementation based on a modular software architecture. Flexible rights and role concept was developed to support efficient collaboration of the heterogenic professions.
Results: The routine usage of 342 users with 8 different roles, 2,219 registered patient cases within the last 4 years and first results of the integrated benchmarking solution give a positive impression regarding feasibility and effectiveness.
Conclusion: To this point, a comprehensive infrastructure for the Ambulatory Tyrolean Stroke Pathway has been established. Results from outcome analyses and comparative studies could help to further improve usability and to expand the area of application for other indications.
Keywords: digital health; disease management programs; integrated health care systems; outpatient rehabilitation; patient care management; stroke; stroke rehabilitation.