Challenge

Clinical guidelines generally focus on individual diseases, making them difficult to apply to patients living with several chronic conditions. Without shared information and coordination, these patients often receive fragmented care from separate medical, social and informal caregivers. Conflicting treatment recommendations and the use of multiple medicines can create additional risks.

Solutions

C3-Cloud developed a digital infrastructure through which multidisciplinary care teams, patients and informal caregivers could jointly create, manage and update personalised care plans. Decision-support tools helped reconcile clinical guidelines, assess risks, manage polypharmacy and set treatment goals. The platform connected with existing health and social care systems through interoperability middleware and an integrated terminology service, incorporating patients’ needs, preferences and psychosocial circumstances. The approach was tested in three European regions, focusing on combinations of diabetes, heart failure, renal failure and depression.

Results

C3-Cloud demonstrated how ICT could support more coordinated and personalised care for people with multiple chronic conditions. The pilots strengthened evidence on the system’s acceptance, usability and potential efficiency gains while improving cooperation and secure information exchange among professionals, patients and informal caregivers. The project also produced validated care pathways, organisational models, training materials and change-management guidelines for wider European use. Commercial uptake was supported through an Industry Vendor Forum and the integration of project solutions into the electronic health and personal health record products of three SMEs.