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
diseases:

– 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.

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