PICASO – A Personalised Integrated Care Approach for Service Organisations and Care Models for Patients with Multi-Morbidity and Chronic Conditions

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PICASO is a research project funded by the European Commission’s Horizon 2020 research and innovation program, addressing main challenges in Europe’s healthcare systems, managing multi-morbidities, coordinating care and treatment across organizational units and adapting ehealth solutions to existing care models and plans.

The project aims to develop an ICT platform for integrated care that supports collaboration between all stakeholders involved in the care and treatment of people diagnosed with multiple chronic diseases, cardio vascular disease and either Rheumatoid Arthritis or Parkinson’s disease. The main stakeholders are physicians like GPs, cardiologists, rheumatologists or radiologists, medical personnel like physiotherapists as well as patients, relatives and (informal) caregivers. PICASO also aims to promote empowerment of patients in regard to self-health management in everyday life.


The main objectives of the project are:

  • to support the coordination of care and treatment plans across different sectors PICASO will ease the creation of care plans within the integrated care platform and improve clinical decision support for physicians. Every care plan will be exported to an appropriate machine-readable format that is prerequisite for decision support. The clinical decision support will be based on analysis of conflicts, constraints and limitations from single-morbidity care plans as well as risk prediction models for the interpretation of patient’s immediate and future health status based on patients’ risk scores.
  • to ensure comprehensive data protection and handling data in a privacy compliant manner for all stakeholders PICASO will comply with the European “General Data Protection Regulation” (GDPR) from 2016 and national regularizations of Germany and Italy, where pilot sites will take place.
  • the foreseen management and security model will provide a unique information sharing system with a distributed shared memory object space, where the physically separated data storages can be addressed as one logically shared address space, while data can be stored in one place, i.e. the requestor’s (data owner) legacy repository. Role based access to patient`s data is bound on informed patient consent.
  • to promote patient empowerment and self-care PICASO will offer with easy to understand information on symptoms, treatment and medication, reminder services e.g. for drug intake as well as an integrated view on relevant personal health parameter. An app will provide a graphical view showing values for e.g. blood pressure or heard rate variability from the integrated home monitoring and self-ratings of well-being or pain rates together with the taken medications and can be displayed as daily, weekly or monthly overview. Increased knowledge and visibility of one’s own data and health status are central steps towards empowering the patient and making her or him more involved in treatment decisions.

Fraunhofer FIT is coordinator of the project and leads the user requirements engineering process. Beyond this FIT will develop a service that supports clinicians in creating an individual care plan that can be aligned with already existing care plans for a patient and will draws attention to possible conflicts.

Pilot sites

The PICASO platform will be evaluated at two pilot sites, in Germany at the Policlinic of Rheumatology at the University Hospital of Düsseldorf and in Italy at the University Hospital of Tor Vergata in Rome. The trails in Düsseldorf focus on patients diagnosed with Rheumatoid Arthritis and in Italy, on patients with Parkinson’s disease. On both trial sites patients involved in the trials are also suffering from a Cardio Vascular Disease as co-morbidity.

The overall purpose of the trials is a proof of concept to demonstrate that PICASO services enable collaborative sharing of patient information, particularly care plans for a more holistic view of patients with comorbidities and potential problems within the complete treatment plan. The trials will also validate impact of the PICASO integrated care platform on the effectiveness of the care systems and acceptance of home monitoring services by patients and relatives.


  • Fraunhofer Institute for Applied Information Technology (DE)  
  • CNet Svenska AB (SE)
  • In-JeT ApS (DK)
  • Research Institute Fondazione Inuit Tor Vergata (IT)
  • Technical Universtiy of Kosice (SK)
  • Vrije Universiteit Brussel (BE)
  • University of Rome “Tor Vergata” Hospital (IT)
  • Heinrich-Heine-University Düsseldorf, Universitätsklinik Düsseldorf (DE)