C3-Cloud aims to develop personalised care plans for complex multimorbid patients, supported by ICT tools and managed by a coordinated multidisciplinary team, that promotes integrated care and the involvement of the patient and/or caregiver.
This will be achieved through the following work tasks:
- • A Personalised Care Plan Development Platform will allow collaborative creation and execution of personalised care plans for multimorbid patients through systematic and semi-automatic reconciliation of clinical guidelines, with the help of:
• Decision Support Modules, recommendation reconciliation, poly-pharmacy management and goal setting.
• Development of C3-Cloud Interoperability Middleware for seamless integration with existing information systems, and fusion of multimodal patient and provider data.
• Providing an Integrated Terminology Server with advanced semantic functions to enable meaningful analysis of multimodal data and clinical rules.
• Supporting active patient involvement and treatment adherence through a Patient Empowerment Platform ensuring patient needs are respected in decision making and taking into account preferences and psychosocial aspects.
• Co-design and 4-layered multi-method multi-stakeholder evaluation will lead to a user friendly solution.
• Demonstrating feasibility through pilot studies focusing on diabetes, heart failure, renal failure, depression in different comorbidity combinations. Pilots will be undertaken in 3 European regions with diverse health and social care systems and ICT landscape, which will allow for strengthening the evidence base on health outcomes and efficiency gains.
• Validation of C3-Cloud adaptive patient pathways and organisational models by patient organisations and a clinical reference group, change management and training guidelines will be shared with the European community.
• Facilitating commercial exploitation of C3-Cloud integrated care solutions through an Industry Vendor Forum and commercial EHR/PHR products of 3 leading SMEs.