RESUMO
This paper originates from the HeartDrive project, a platform of services for a more effective, efficient and integrated management of heart failure and comorbidities. HeartDrive establishes a cooperative approach based on the concepts of continuity of care and extreme, patient oriented, customization of diagnostic, therapeutic and follow-up procedures. Definition and development of evidence based processes, migration from parceled and episode based healthcare provisioning to a workflow oriented model and increased awareness and responsibility of citizens towards their own health and wellness are key objectives of HeartDrive. In two scenarios for rehabilitation and home monitoring we show how the results are achieved by providing a solution that highlights a broader concept of cooperation that goes beyond technical interoperability towards semantic interoperability explicitly sharing process definitions, decision support strategies and information semantics.