**3. xCARE in action**

Among the different implementations we have implemented and we are currently implementing by using xCARE as baseline, in the following, we present how xCARE has been used for providing self-management to complex chronic patients in the CONNECARE project and for supporting behavioral change through a recommender system in the CarpeDiem project.

#### **3.1 Self-management of complex chronic patients**

The project CONNECARE (Personalized Connected Care for Complex Chronic Patients) is a H2020 Research and Innovation Project, started on April 2016 and finished on December 2019. CONNECARE is a technologically-oriented initiative aiming at exploring digital tools to support two key requirements of integratedcare services for chronic patients, namely: (i) Smart adaptive case management of patients with multimorbid conditions; and, (ii) Collaborative work among the various stakeholders, including patients and their families across health and social care tiers, involved in the services. The CONNECARE approach uses an observational study design, focused on implementing the CONNECARE organizational model and technology in a real life clinical setting, with an intervention group and matched control group and four implementation sites: Barcelona and Lleida in Spain, Ashdod in Israel, and Groningen in The Netherlands.

*xCARE: A Development Platform for Supporting Smart and Pervasive Healthcare DOI: http://dx.doi.org/10.5772/intechopen.95951*

**Figure 2.** *The CONNNECARE overall system.*

The CONNECARE system has been deployed in two situations: 1) Communitybased prevention of unplanned hospital-related events in chronic complex patients with high risk for hospitalization; and 2) Preventive patient-centered intervention in complex chronic patients undergoing elective major surgical procedures. While the objectives and desired outcomes are the same in all sites, the organizational model for integrated-care and the supporting digital tools have been adapted to the specific needs of each site.

The CONNECARE system, depicted in **Figure 2**, is composed of a Self-Management System (SMS), installed on patients' smartphones (or tablets), and the Smart Adaptive Case Management system (SACM), accessible via Web. The SMS allows monitoring patients and providing engagement, rewards, and warnings [8]. The SACM has extended functionalities for case management to define a case according to an organizational model based on a 5-dimension score strategy: Case Identification, Case Evaluation, Workplan definition, Workplan execution, and Discharge [9]. Additionally, the SACM includes an advanced Clinical Decision Support System focused on helping clinicians in risk assessment and stratification and a visual support tool for locating the patients and organizing their visits [10]. The SMS and SACM interact each other through the CONNECARE Enterprise Service Bus which connects both subsystems and orchestrates their communication. All professionals, including health professionals from both primary care and hospitals and social workers, interact with each other using a direct communication tool to coordinate the patient's care plan and its execution, assuring continuity of care between hospital, primary-, and social-care. Patients continuously check their status and execute their assigned tasks through the SMS. Hospital staff, primary care professionals, and social workers may also help and accompany the patients using the messaging. CONNECARE provides also an integration framework to link its services to specific Electronic Health Records and regional Personal Health Folders.

The CONNECARE SMS has been built upon the xCARE platform. **Figure 3** sketches the adaption that has been done. In total, 12 microservices have been defined and developed, 7 of them specifically to perform patient's monitoring (5 for basic- and 2 for advanced-monitoring) and 5 are for giving support and providing further functionalities:

#### **Figure 3.**

*xCARE adapted to CONNECARE.*

	- Physical activity, to monitor the number of steps performed every day and the minutes of activity (low, medium, high, and sedentary). Wristbands from Withings8 and Fitbit9 have been integrated through the interaction with the corresponding APIs. Moreover, wristbands from LifeVit10 have been directly integrated by relying to the Bluetooth connection.
	- Sleeping, to monitor sleeping data (sleep time per night, minutes that the user has been awake during the night sleep, and sleep time during the day) through the wristbands used for monitoring the physical activity.
	- Questionnaires, to assign one or more questionnaires to a patient; settingup of the questionnaire(s) to be answered, together with the frequency that questionnaires will be requested to the patient's under the medical surveillance provisions; sending back questionnaire answers to the clinician; and checking the list of prescribed questionnaires and their answers.
	- Simple tasks, to monitor the performance of specific tasks during the day (e.g., dancing, cooking, reading). Moreover, depending on the disease and the kind of patient (e.g., in case of elderly people) the professional may ask to perform healthy activities such as drinking or eating a fruit. Through the self-management system, the patient can accept or reject the request and check when the activity has been performed.
	- Health status, to monitor the health status of patients through the integration of suitable medical devices (e.g., blood-pressure monitor, thermometer, and pulse-oximeter). Devices from Withings have been selected because of the availability of the API and the possibility to ingrate

<sup>8</sup> https://www.withings.com/es/en/

<sup>9</sup> https://www.fitbit.com/

<sup>10</sup> http://lifevit.es/

them via Bluetooth or WI-FI. In case of traditional medical devices were preferred, also the manual input from the patients was allowed.

	- Advice, to allow professionals to select pieces of advice and training material in the form of text, images, or videos that patient is asked to see. The patient may create her/his own list of bookmarks to have a direct access to relevant information any time is needed. Four categories of advice have been defined: automatic advice (generated by the system according to the collected data), personalized advice (written by the professional for a specific patient), educational material (specific of a given case study in a specific site and common to all the patients of the corresponding case and site), and health educational videos (specific for a given site and common to all the patients to that site).
	- Messaging, to offer a bidirectional communication that allows patients to interact with members of the medical staff in charge of the case, a given clinician, or even with other patients or communities of patients. Similarly to the well-known Whatsapp app, patients may send/receive text, images, videos, links, and documents.
	- Recommendations, to send recommendations on physical activity [11].
	- Notifications, it receives the notifications generated by any of the other microservices whose recipient is the patient (e.g., a new prescription has been generated). Complex notifications coming from interaction with the patient's monitoring microservices may also be sent.
	- Alerts, as soon as a patient's monitoring microservice finds an anomaly, it interacts with this microservice and a suitable alert message is sent to both the patient (to be aware of the issue) and the clinical staff (to be informed and act accordingly). Anomalies are triggered any time the data gathered from the patient (e.g., through the medical devices or a questionnaire) exceeds a given threshold defined at prescription time (e.g., a critical heart rate value).
	- Third party, to integrate third party elements, such as wearable and medical devices. This microservice has two main functionalities: managing the connections to external providers and standardizing the data model.

A total of 301 patients have been involved. Satisfaction of patients and carers with the SMS has been evaluated by relying on the Likert Scales/Net-Promoter-Score [12] and the System-Usability-Scale11. Overall, the satisfaction was high, despite a significant number of challenges encountered along the way. Satisfaction was clearly linked to the perception that the SMS was part of an overall integratedcare process and the relationship between professionals and patients. Finally, the User eXperience analysis performed in Lleida (Spain) shows that, in order to

<sup>11</sup> https://www.usability.gov/how-to-and-tools/methods/system-usability-scale.html

#### **Figure 4.**

*Sample screenshots of the CONNECARE app showing: (a) the feedback on physical activity, (b) the administration of a questionnaire, (c) the follow-up of a drug prescription, and (d) the communications with the team of professionals.*

improve satisfaction and engagement, patients need to perceive the app as relevant and that it gives them a clear and simple added value [13].

The CONNECARE SMS is an app available in both Apple App Store and Google Play markets12. **Figure 4** shows some screenshots of the CONNECARE SMS: (a) the feedback on physical activity in terms of number of steps, (b) the administration of the EQ-5D-5 L questionnaire, (c) the follow-up of the drug prescription of Ipratropium, and (d) the communications with the team of professionals showing the list of actions the patient may do.
