Founding integrated care models

Analysis of the care plan management, guidelines and handover procedures in the two clinical partner institutions has resulted in a set of recommendations for the PICASO platform.

The PICASO platform is integrating data from the various healthcare professionals that a patient is in contact with to support the sharing of data across these sectors and obtain coordinated care plans, tailored to the need of the individual patients. Trial sites are the University Hospital of Tor Vergata in Rome and the University Hospital of Düsseldorf who have started identifying where and how the PICASO system can be evaluated in the two clinical trials, involving patient groups with Parkinson’s disease and Rheumatoid Arthritis.

During initial discussions, the following recommendations for PICASO functionalities surfaced covering data capture, visualisation and exchange:

  • PICASO shall aim at supporting the caring physicians to follow the various available guidelines by providing data that are prerequisites for the fulfilment of the guidelines and that are rarely always collected by the specialist alone;
  • Alerts and events are highlighted in the graphical user interface when entering the PICASO platform so that the healthcare professional becomes aware of new entries;
  • Automatic check of available data for risk assessment issues as well as a list of what data are missing before risk assessment can be completed;
  • Risks are made available to all relevant, accredited healthcare professionals so care is taken for the patient in whatever setting she is in. The new data generated would then be available in the next step to others, and thus allow timely decision support;
  • Visualisation of patient data from the various sources should be readily accessible for the clinician and easy to digest during appointments;
  • Data exchange should happen electronically instead of being paper-based.

In addition, the Italian trial stresses the importance of giving informal carers, such as relatives, access to relevant information including medication plans, clinical appointments and home monitoring data since in Italy, the relatives play a central role in the care of the older generation.

The recommendations have resulted in a range of requirements which are continuously processed, considering the aims of the project.

Patient empowerment and protection

To protect the rights of the patients in the trials, informed consent from the participating patients is acquired to exchange their data among healthcare professionals and to enable them and/or their informal carers to visit the PICASO platform regularly and see their data.

The increased knowledge and visibility of one’s own data and health status are central steps towards empowering the patient, making him or her more involved in the decisions;

The patient should be able to have control over his or her personal data, determining who has access to what information and when. However, the patient also needs to know the implications; if data are not available due to the patient restricting the sharing of data, certain guidelines and care plan recommendations cannot be fulfilled, explains Senior Consultant, Trine Sørensen from In-JeT ApS, who is Ethical Manager in PICASO.

PICASO follows standard ethical principles as well as current legislation when dealing with real patients. An ethical board has been appointed to ensure that the PICASO project trials are executed in an ethically sound manner and in accordance with relevant national and international ethical and legal requirements for trials involving real patients.

The ethical guidelines in PICASO are based on the main principles of respect, beneficence, justice, confidentiality and privacy which all project partners have committed to honour, says Trine Sørensen.

You can read more about PICASO work on ethics and protection of the patient in the deliverable D3.3 The PICASO Ethical Guidelines.

How PICASO helps create coherent care plans for people with multiple chronic conditions

Better coordination of care plans between healthcare sectors is high on the European health agenda. So is
efficient management of the steadily rising number of patients with co-existing chronic conditions. The
PICASO project aims to develop information and communication technologies which meet these demands,
by supporting a continuum of care from hospitals and outpatient clinic to the home:

– The PICASO platform will enable the sharing of a patient’s complete care pathways with tools to
establish health status, predict risks and adjust care. Based on monitoring of different physiological
parameters at home, the patients can actively participate in their own care. The result is better
management of co-existing diseases and coordination of care plans for the benefit of patients and
carers across organisations, explains Project Coordinator, Dr. Markus Eisenhauer from Fraunhofer
Institute for Applied Information Technology.

Trials in Italy and Germany
To demonstrate the platform and its wide applicability, the technologies will be trialled in two different
national settings with two different patient groups, counting up to a 100 patients: in Italy, the University
Hospital of Tor Vergata in Rome will enrol patients with Parkinson’s disease and in Germany, the University
Hospital of Düsseldorf will engage patients diagnosed with Rheumatoid Arthritis. Both patient groups have
Cardiovascular Diseases as co-morbidities and both settings share the complexity of treating co-occurring

– Clinical treatment of people with co-morbidities is much more complex than treatment of patients
with a single condition since treating one chronic condition can have negative effects on another.
The treatment is also very individual and patients have to work closely with doctors and therapists to
establish a suitable patient programme, accommodating the patient’s particular and changing needs.
PICASO can support the management of these programmes which involves different disciplines,
multiple care channels and actors, explains Dr. Agostino Chiaravalloti from the University Hospital of
Tor Vergata.

His view is backed up by PD Dr. Jutta Richter from the Policlinic of Rheumatology and Hiller Research Unit
at the University Hospital of Düsseldorf who concludes:

– The trials will establish how PICASO can improve the exchange of data between stakeholders in the
workflow and validate the effect of PICASO on the care systems as well as the acceptance of the
system by the wider group of stakeholders such as patients, relatives and the society at large.