The solution

INCA Solution will provide an initial multidimensional assessment through tailored questionnaires for an early identification of Patients with Multi Morbidity (PMM) and a pre-defined workflow for these patients enrolment. This will be done thanks to incorporating patient’s data collected from many sources, including social and health information, together with other data such as physical activity.

The platform will also provide tools to share care plans between professionals and patients and/or caregivers. Our Shared Care Plan (SCP) will offer a centralized coordination between different care levels, involving the whole professional team in real time to do adapt plans. However, it will present different permission levels to patient information depending on the various professional roles. This will allow the solution to share the correct information with the right person.

A Multidisciplinary Care Centre will be supported and will oversee PMM, checking the rationalization of visits, medication reviews, etc., from a holistic point of view.

INCA Solution is placing the patient at the centre and enables a multichannel communication platform, adding an alarm and alert system with quantitative and qualitative triggers for early decompensation detection.

In addition, INCA Solution will have a clinic decision support system based on AI to enhance PMM attention and coordination, as well as automatic processes depending on triggers to reduce clinical variability not justified.

From a patient point of view, INCA Solution will count with a specific and differentiated App for patients (adapted to different patient profiles) as well as for caregivers and/or relatives. This App will be the patients tool to manage their information and shared care plan, with the aim of empowering them and achieving patient co-responsibility, and will also include a gamified system to motivate in improving their adherence to treatment and to healthy habits, or even helping to increase their health or digital literacy.


INCA’s partners form a strong and complementary consortium, providing their specific expertise but able to act as a co-creation team. Fight Infections Foundation (FII) and Germans Trias i Pujol Research Institute (IGTP) are both entities with huge experience in health care services, in chronic conditions patients’ management, in clinical research and in Healthcare Digital Transformation projects. IGTP stands out for its technology transferring mindset and FLI is used to support spin-off’s creation.

Additionally, the Faculty of Health Sciences at Open University of Catalonia (UOC) and the Norwegian Centre for E-Health Research (NOR), both WHO members, are specialized in eHealth ecosystem research and best practices in eHealth adoption. UOC with presence in Spain and NOR with capacity to coordinate deployments in Sweden and Norway.

Last but not least, Doole Health (DOOLE) core business is a Telehealth Platform for virtual medical visits that strengthen the link between patients and health professionals. The platform provides added value to the patients while optimizing resources in terms of time, costs, and distance at both ends and allowing access to new segments of care and outpatients. Doole has been recognized in several innovation forums and currently has presence in Spain, Andorra, Chile and Argentina.

Motivation and Goals

The specific motivation of each professional lies in the benefits solving CareMatrix challenge will bring to their day-to-day. Clinical partners (FLI and IGTP) expect to achieve a solution that will save them time (less hours coordinating care plans or having pre-defined alarms to detect exacerbations), reduce

PMM re-admissions, reduce clinical and administrative errors and allow them to follow-up patients in one place (interoperability).

On the other hand, the research centres (UOC and NOR) aim to contribute in a solution that goes beyond the state-of-the-art and is able to prove how e-health technologies (remote consultation, monitoring or self-management tools) benefit patients with multimorbidity.

From Doole’s perspective, including a new use case such as PMM will help to enrich its current telemedicine platform, providing learnings on how to optimally manage patients with more than one condition at a time. At the end, all team members have in mind the same goal: improve healthcare services for PMM.

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