Management of personalised guideline-driven care plans addressing the needs of multi-morbidity via clinical decision support services

Introduction: The clinical management of patients suffering from multiple chronic conditions is very complex, disconnected and time-consuming with the traditional care settings. C3-Cloud project aims to build an integrated care platform for addressing the growing demand for improved health outcomes of multimorbid and long-term care patients. Theory/Methods: C3-Cloud has established an ICT infrastructure enabling continuous coordination of patient-centred care activities by a multidisciplinary care team MDT and patients/informal care givers. The Coordinated Care and Cure Delivery Platform C3DP allows, collaborative creation and execution of personalised care plans for multi-morbid patients through systematic and semi-automatic reconciliation of clinical guidelines. Clinical decision support CDS systems implementing flowcharts from evidence based clinical guidelines are integrated to present suggestions for treatment goal and activities e.g. medications, follow-up appointments, diet, exercise, lab tests. Pilot site local care systems are integrated with the C3DP via the technical and semantic interoperability platform to facilitate informed decision making. Active patient involvement is realized through a Patient Empowerment Platform presenting personalized care plan to the patient and establishing a continuous bi-way communication with the patient to collect patient observations, questionnaire responses, symptoms and feedback about care plan goals and activities. Results: The following research results have been achieved to enable guideline enabled personalised care plan management for addressing the needs of multi-morbidity: 43 logical flowcharts were designed out of 4 disease guidelines Type 2 Diabetes, Heart Failure, Renal Failure and Depression. 181 CDS rules assessing 166 patient criteria and recommending 154 goal/activity suggestions were implemented as CDS services in GDL covering T2D and RF. 52 reconciliation rules were designed for eliminating contradicting guideline recommendations due to multi-morbidity. 23 HL7 FHIR profiles were defined for representing care plan and patient data. C3DP has been integrated with these CDS services via CDS-Hooks specification to recommend personalised care plan goals and activities. Discussions: In this research, we have successfully implemented an ICT infrastructure enabling guideline-driven integrated care for multi-morbid patients. Although our ICT solution covers all the technical requirements identified by clinical partners, effective implementation of integrated care in real-life care setting requires major changes in organisational responsibilities and care pathways. Conclusions: User-centred design and usability testing have successfully been completed. C3-Cloud pilot application will now be operated in 3 European pilot sites with the participation of 62 MDT members and 1200 multi-morbid patients for 15 months. Lessons learned: There are two main research lines for reconciliation of contradicting guideline recommendations: 1 fully-automated reconciliation via ontology reasoning, 2 manually-crafted reconciliation rules by clinical expert groups. Although first approach is more dynamic, research results are still for very primitive cases and not clinically validated. As we are targeting an industry-ready solution after piloting in real-life settings, we have opted for the second option. Limitations: When a new chronic disease is to be addressed within our platform, reconciliation rules covering all disease combinations have to be re-assessed by the clinical expert group. Suggestions for future research: Fully-automated reconciliation approaches need to be further studied and validated in real-life settings

Enabling patient adherence via personalised, just-in time adaptive interventions in ADLIFE architecture

Chronic diseases introduce challenges for the patients to continuously be involved in their care activities and manage the changing requirements of their disease. Patient empowerment activities are a critical component to assist patients in their long-term care journey. In the ADLIFE project (H2020, SC1-DTH-11-2019, 875209), an integrated care planning approach is used where patients are assigned various care plan activities by multidisciplinary care teams. To increase patients’ adherence to the care plan, a continuous behavioral monitoring architecture is developed for delivering digital personalised, just-in time adaptive interventions

A collaborative platform for management of chronic diseases via guideline-driven individualized care plans

Older age is associated with an increased accumulation of multiple chronic conditions. The clinical management of patients suffering from multiple chronic conditions is very complex, disconnected and time-consuming with the traditional care settings. Integrated care is a means to address the growing demand for improved patient experience and health outcomes of multimorbid and long-term care patients. Care planning is a prevalent approach of integrated care, where the aim is to deliver more personalized and targeted care creating shared care plans by clearly articulating the role of each provider and patient in the care process. In this paper, we present a method and corresponding implementation of a semi-automatic care plan management tool, integrated with clinical decision support services which can seamlessly access and assess the electronic health records (EHRs) of the patient in comparison with evidence based clinical guidelines to suggest personalized recommendations for goals and interventions to be added to the individualized care plans. We also report the results of usability studies carried out in four pilot sites by patients and clinicians

Localisation, personalisation and delivery of best practice guidelines on an integrated care and cure cloud architecture : the C3-cloud approach to managing multimorbidity

Background: C3-Cloud is an integrated care ICT infrastructure offering seamless patient-centered approach to managing multimorbidity, deployed in three European pilot sites. Challenge: The digital delivery of best practice guidelines unified for multimorbidity, customized to local practice, offering the capability to improve patient personalization and benefit. Method: C3-Cloud has adopted a co-production approach to developing unified multimorbidity guidelines, by collating and reconciling best practice guidelines for each condition. Clinical and technical teams at pilot sites and the C3-Cloud consortium worked in tandem to create the specification and technical implementation. Results: C3-Cloud offers CDSS for diabetes, renal failure, depression and congenital heart failure, with over 300 rules and checks that deliver four best practice guidelines in parallel, customized for each pilot site. Conclusions: The process provided a traceable, maintainable and audited digitally delivered collated and reconciled guidelines

Drug interaction advisory service for clinical decision support of multimordity patient centric care plans in the C3-cloud system

C3-Cloud is a project aiming to provide an ICT infrastructure, which will allow patient centric and integrated care, based on best practice guideline, for patients with multi-morbidity. The collaborative cure and care plan lies at the heart of the system, allowing healthcare professionals to manage the patients’ conditions. Clinical Decision Support, enhances this capability by offering recommendation based on guidelines, but also checking the patient’s record for known adverse interactions when the medication changes. The drug interaction advisory service provides recommendations in the three languages used in the project’s pilot sites, for over 1000 substances, based on the UK’s NICE BNF body of knowledge. The service can be integrated with any system using its RESTful API and by rendering results in JSON

Personalised Care Plan Management Utilizing Guideline-Driven Clinical Decision Support Systems

Older age is associated with an increased accumulation of multiple chronic conditions. The clinical management of patients suffering from multiple chronic conditions is very complex, disconnected and time-consuming with the traditional care settings. Integrated care is a means to address the growing demand for improved patient experience and health outcomes of multimorbid and long-term care patients. Care planning is a prevalent approach of integrated care, where the aim is to deliver more personalized and targeted care creating shared care plans by clearly articulating the role of each provider and patient in the care process. In this paper, we present a method and corresponding implementation of a semi-automatic care plan management tool, integrated with clinical decision support services which can seamlessly access and assess the electronic health records (EHRs) of the patient in comparison with evidence based clinical guidelines to suggest personalized recommendations for goals and interventions to be added to the individualized care plans