Careplans in complex chronic care

Important results from the project

The aim was to achieve planned data collection in a clinical environment using data for several purposes, including individual medical records, quality work and clinical research. The concepts (terms) used need to be coordinated across diagnoses and areas of use. The data model and annotation need to meet the security requirements of healthcare. The goal was to test these concepts in a sharp clinical environment.

Expected long term effects

Patients are now treated according to a care plan based on national guidelines. The effect of additional diagnoses is managed through integration at the terminology level. Transactions can be handled integrated for several processes (clinic, quality, clinical research) and data can be routed to EMR, quality DB and CRF, respectively. Technical development has reached the set goals including some components reaching commercial phase. Large-scale clinical implementation that was part of the goal is ongoing but will be completed by end of year.

Approach and implementation

The theory formation and basic testing took place at Karolinska Institutet, software development by KI and Frisq with implementation within VGR. Collaboration with the clinic has taken place on an ongoing basis and an embedded observational study is underway. Analysis: The developed strategy for semantic interoperability enables the transaction engine to handle several care plans simultaneously. Existing data infrastructure is a challenge. We can monitor the use of data with very high resolution in accordance with the GDPR.