Trillium II /Focus workshop at Informatics for Health2017: Manchester, April 24-27, 2017 Frailty is an age-related state of vulnerability to the risk of adverse health out-comes after a stressor event. The condition predisposes individuals to progressive decline in different functional domains, leading to falls and fractures, disability and dependency on others, hospitalization, institutional placement and ultimately death. We discuss drivers, challenges and opportunities for healthcare information standards related to frailty in old age in an effort to launch a call for coordinated action across research, policy, and academia. Key issues are selected as the back-drop for this discussion: EHR, patient summaries and frailty in a context of coor-dinated care enabled by health IT standards. Presentation 1 of 5: Silvina Santana University of Aveiro

1. Silvina Santana, University of Aveiro
Frail elder citizen trajectories:
user story as starting point and
reflection opportunity
Healthcare information standards for
frailty: why, when and how?
Informatics for Health 2017, Manchester, 25 April

2. John Smith
A TALE IN SEVERAL
ACTS
• Aged 80 years old.
• 1.80 m tall, he has weighed around
70 Kg for the last few years.
• Lives with his wife Ann in a small
house in the suburb of a small city.
• The house has two floors and the
bedroom and bathroom are on the
2nd floor. There is a small toilet on
the 1st floor.
• He is almost autonomous in the
activity of daily living (ADL 5/6; -1
because of urinary incontinence) and
in the instrumental activities of daily
living (IADL 4/5; -1 because his
drugs are prepared by his wife).

3. John Smith
A TALE IN SEVERAL
ACTS
• Used to visit his GP regularly for
check-up examination.
• Took medications for a moderate
hypertension and for hyperlipidemia,
also acetyl salicylic acid.
• Cognitive screening, physical
examination and blood tests were
normal.
• Blood pressure was well controlled.
• He paid attention to his diet and
walked regularly.

4. John Smith
A TALE IN SEVERAL
ACTS
• Three months ago, John underwent
surgical removal of a prostatic
adenoma and developed a serious
urinary tract infection, remaining
hospitalized for 2 weeks.
• Since discharged, he lost 5 Kg, kept
feeling tired and refused to leave his
house and to perform everyday
activities as he used to.
• He kept falling without apparent
cause and with increasing frequency.
• Last time his wife has found him on
the floor, he was very confused and
unable to report for how long he has
there.
• He had a strong pain in the left leg
and was unable to stand up.

5. John Smith
A TALE IN SEVERAL
ACTS
• John arrived to the emergency
department in very bad conditions.
• Very agitated, unable to refer his
medical history or current therapy.
• He was hospitalized and underwent
hip replacement with a prosthesis.
• Treated with many sedatives and
finally an anti-delirium therapy.
• He was transferred to a specialized
rehab unit and then a general
geriatric rehabilitation regimen.
• Lost many of his previous abilities
and need a cane to walk.
• He was moved to a residential home.
• After 1 month there, he finally got
home with prescription of
physiotherapy at home, cane and
wheelchair to move outside.

7. John Smith
A TALE IN SEVERAL
ACTS
How is responsibility managed among all care professionals
(doctors, nurses, social workers, caregivers, care managers etc.)
What information about the patient health status would be required
to ensure efficient professional help along the entire pathway?
What information about the patient is necessary to assure a
smooth transfer among different health care entities?
What kind of data should the patient summary provide to optimize
care in planned and every day settings?
What kind of data on frailty status is necessary if any?