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A Federated Collaborative Care & Cure Cloud Architecture for Addressing the Needs of Multi-morbidity

and Managing Poly-pharmacyGokce Banu Laleci Erturkmena, Mustafa Yuksela, and Theodoros N. Arvanitisb

a SRDC Software Research Development & Consultancy Corp, Ankara, Turkey, email: (gokce, mustafa)@srdc.com.trb Institute of Digital Healthcare, WMG, University of Warwick, Coventry, UK , email: T.Arvanitis@warwick.ac.uk

IntroductionA growing share of the population (15% in 2010) in OECD

countries is over 65 and expected to reach 22% by 2030. Older age isassociated with an increased accumulation of multiple chronicconditions. More than half of all older people have at least threechronic conditions, and a significant proportion has five or more.

The clinical management of patients with multi-morbidity is muchmore complex, disconnected and time-consuming than that of thosewith single diseases. As a result, multi-morbid patients with long-termcare needs experience shortcomings and gaps in their care provision.

There is an increasing need to organise the care around the patientwith the involvement of all stakeholders, and as a response to thisrequirement, the C3-Cloud project aims to achieve high qualityintegrated care with the support of information and communicationtechnologies (ICT).

C3-Cloud ApproachC3-Cloud establishes an ICT infrastructure to enable continuous

coordination of patient-centred care activities by a multidisciplinarycare team (MDT) and patients/informal care givers.

Reconciliation of Multiple Care Plans through Clinical Decision Support Systems

Clinical Decision Support Modules are utilized for risk predictionand stratification, poly-pharmacy management, goal and interventionsetting based on evidence based clinical guidelines and reconciliationof multiple care plans.

Seamless integration with existing health/social care information systems

Fusion of multimodal patient data will be achieved via C3-CloudInteroperability Middleware. FHIR based interfaces with existinghealth/social care information systems are being implemented foraddressing technical interoperability, while a terminology server isutilized for addressing semantic interoperability challenges.

Active Patient Involvement through Patient Empowerment Platform

Active patient involvement will be realized through a PatientEmpowerment Platform, ensuring patient needs are respected indecision making.Project Web Site: http://c3-cloud.eu/

Personalised Care Plan Development Platform A Personalised Care Plan Development Platform allows

collaborative creation and execution of personalised care plans formulti-morbid patients through systematic and semi-automaticreconciliation of clinical guidelines.

Fig. 2 – A snapshot from Personalized Care Plan Development Environment

DM2 + RF-Severity and stage-Diet/exercise-Training and self-care-Follow-up-Pharmacotherapy

RF-Severity and stage-Diet/exercise-Training and self-care-Follow-up-Pharmacotherapy

Severity and stage

classification

Diet, exercise, training and self-care

Follow-up Pharmacotherapy

-Modification of the severity and stage

-Significant modificationsdue to RF-Necessity of new recommendations

-Changes in the content and in thefrequency of visits-Criteria of referral to nephrology

-New drugs-Changes in “ prescription module”: Disease-drug and drug-druginteractions.

INTERACTIONSDisease-diseaseDisease-drugsDurgs-diseases

Drug-drug

DM2-Severity and stage-Diet/exercise-Training and self-care-Follow-up-Pharmacotherapy

DM2 Care PlanGoalsHbA1c ControlLipid controlBP control Weight Loss

InterventionsMetformin Treat.Statin TreatmentACE-I TreatmentDiet & Exercise

RF Care PlanGoalsMonitor ProgressManage CVD RiskBP controlSelf Management

InterventionsRASA Treatment.Diet & Exercise

InteractionsDisease-Disease

Disease-drugsDrugs-Disease

Drug-Drug

DM2 & RF Care PlanGoalsHbA1c ControlLipid controlBP control Weight Loss

InterventionsInsulin TreatmentStatin (Decreased dose)RASA TreatmentDiet & Exercise

DM2 Clinical Guidelines RF Clinical Guidelines

Clinical Decision Support Modules

Personalized Suggestions forgoals and interventions

Reconciliation of Care Plans

Personalized Suggestions forgoals and interventions

The research leading to these results has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 6891810, C3-Cloud Project

Fig. 3 – Utilization of Clinical Decision Support Modules for Care Plan Creation and Reconciliation of Multiple Care Plans

Fig. 1 - An overview of C3-Cloud Architecture

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AFcRoll Up_ trillium3.pdf 3 15/03/19 13:38