A Collaborative Platform for Management of Chronic Diseases via Guideline-Driven Individualized Care Plans

Abstract

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.

Keywords: Chronic disease management; Clinical decision support systems; Evidence based clinical guidelines; Integrated care.

Graphical abstract

Fig. 1

The basic concepts of the C3-Cloud system.

Fig. 2

High level system architecture.

Fig. 3

TIS interfaces to local EHR systems for fetching patient data.

Fig. 4

Semantic interoperability suite architecture.

Fig. 5

Semantic mapping example.

Fig. 6

A sample flowchart for lipid managment CDS.

Fig. 7

A screenshot of the diabetic foot problem guideline in GDL2 editor.

Fig. 8

Patient empowerment platform - care plan details screen.

Fig. 9

Care plan summary screen of C3DP.

Fig. 10

Building blocks of a care plan.

Fig. 11

A snapshot from C3DP presenting personalized activity suggestions.

Fig. 12

Set of 118 words for the “product reaction cards” [43].

Fig. 13

Learning (C3DP).

Fig. 14

Getting started is (difficult – easy) (C3DP).