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A Federated Collaborative Care Cure Cloud Architecture for Addressing the Needs of Multi-morbidity and Managing Poly-pharmacy

Periodic Reporting for period 3 - C3-Cloud (A Federated Collaborative Care Cure Cloud Architecture for Addressing the Needs of Multi-morbidity and Managing Poly-pharmacy)

Reporting period: 2019-05-01 to 2020-08-31

There is an increasing need to organise the care around the patient with the involvement of all stakeholders. In response, C3-Cloud aims to achieve high quality integrated care with the support of ICT. C3-Cloud establishes an ICT infrastructure to enable a continuous and collaborative coordination of patient-centred care activities by a multidisciplinary care team, together with patients and their informal care givers, for multi-morbid conditions. More specifically, a Personalised Care Plan Development Platform has allowed, for the first time, collaborative creation and execution of personalised care plans for multimorbid patients, through systematic and semi-automatic reconciliation of clinical guidelines. This has been realised with the help of clinical decision support (CDS) services for risk prediction and stratification, recommendation reconciliation, poly-pharmacy management and goal setting. Fusion of multimodal patient and provider data has been achieved via C3-Cloud Interoperability Middleware for seamless integration with existing information systems. Active patient involvement and treatment adherence has been attained through a Patient Empowerment Platform. Co-design has led to a user-friendly solution and a 4-layered evaluation has demonstrated feasibility in Spain, Sweden and UK with diverse health and social care systems and ICT landscape. The project has focused on diabetes, heart failure, renal failure, depression in different comorbidity combinations. The pilot studies have allowed to gather data for strengthening the evidence base on integrated multimorbid care health outcomes and efficiency gains.
Our main aim was to develop an end-to-end digital integrated care delivery solution for multimorbidity in the context of chronic disease management. The C3-Cloud integrated care approach offers ICT tools for optimized multimorbidity care pathways and organizational models. The C3-Cloud ICT components have been showcased as high technology readiness successes at EU’s Innovation radar (

The project’s achievements are summarised as follows:
1. The project management and communications structures have been developed to oversee activities, monitor risks and issues; and assure quality. Dissemination of results through various channels, such as website, social media, conferences, workshops and publications.
2. Exploitation plans for the project results have led to a final business plan and the incorporation of a community interest company, namely C3-Cloud Partnership Ltd.
3. The design of the technical architecture of C3-Cloud has been completed with co-production between technical and clinical teams throughout software development, testing and deployment phases.
4. Patient pathway and organisational model development and change management for using the tools developed in C3-Cloud have been extensively analysed and guidance developed for new patient pathways and corresponding personalized care plans.
5. The Interoperability Middleware consists of 3 components. The Technical Interoperability Suite enables seamless data exchange between the local care systems and the C3-Cloud components, while the Semantic Interoperability Suite addresses the challenge of heterogeneous clinical data representation formats. Finally, the Security and Privacy Suite enables authentication and authorization of care team members and ensures encrypted and auditable data.
6. The Patient Empowerment Platform (PEP) has been developed for use by patients and their informal caregivers, with messaging and self-management training materials access for increasing patient adherence to care plans.
7. NICE clinical guidelines for the 4 diseases and multimorbidity have been studied. 43 logical flowcharts have been developed that model the clinical recommendations from the guideline text documents to develop 31 CDS services. A drug-drug interaction service has been developed based on the NICE British National Formulary (BNF) database to support care plan development.
8. The Coordinated Care and Cure Delivery Platform (C3DP) has been developed as a web application to allow collaborative creation and execution of personalised care plans for multimorbid patients by a multidisciplinary care team.
9. All the technical components have been successfully integrated and the C3-Cloud system has been successfully deployed at the 3 pilot sites in Spain, Sweden and UK.
10. Protocols have been developed for the 4 layers of evaluation in the project (e.g. component and application test plans, usability evaluation, etc.). Ethics applications have been obtained successfully for the technology trial of the C3-Cloud system at the pilot sites.
11. The study has run for 6 months and the data gathered has helped to inform C3-Cloud system’s acceptance and perform impact assessment in the context of scaling up of the solution.
The C3-Cloud platform offers a complete integrated care plan management solution, which is enriched with novel CDS services that promote the best practice available in evidence based clinical guidelines, hence trying to standardise integrated approaches to care across the healthcare enterprise. 283 clinical rules and 52 novel reconciled clinical rules to manage multimorbidity have been created as 31 computable CDS services. The final outcome is unique, as it deploys in clinical practice, the best-breed of modern standards and specifications (HL7 Care Plan Domain Analysis Model, HL7 FHIR, CDS Hooks, GDL2, OpenID Connect 1.0 OAuth2.0) with an extensible platform implementation for Care Planning, evidence-based care CDS services and patient and informal care giver empowerment – through the C3-Cloud Patient Empowerment Platform. There are several care plan management solutions on the market; however, they are either based on proprietary data models and exchange APIs that makes integration with legacy systems quite hard, or they lack CDS support, or patient empowerment perspective.

C3-Cloud was evaluated with patients, their informal caregivers and healthcare professionals in 3 pilot regions. By means of a mixed methods research design, the tests and evaluation activities generated data to assess the usability and usefulness of the C3-Cloud system as well as its acceptance and satisfaction among user groups. The overall outcome showed a positive perception on the user acceptance and satisfaction for the various ICT components of C3-Cloud. An overall socio-economic return analysis for the whole health service system (systemic SER), patients, primary care services and the payer(s) has demonstrated ways in which integrated care, through the C3-Cloud solution, can change economic and organisational benefits at all levels.

We carefully studied the steps undertaken at the pilot sites as they prepared to accept, install and use the technical solutions in order to provide better and more patient-empowering multimorbidity care. These preparations included obtaining organisational approval for changing care pathways and using novel technical solutions, formalised data protection, data processing and other internal agreements, and training. As a result, we have created a blueprint guide that outlines why multimorbidity care is so important, how organisations should not only use the C3-Cloud solutions but should embrace culture changes in care delivery and EHR record keeping, in order to deliver the best possible care.
C3-Cloud ICT Architecture
C3DP Care Plan View Example
PEP Care Plan View Example
C3-Cloud Consortium
C3DP Medical Summary View Example
C3-Cloud Overall Concept