Background
Chronic Obstructive Pulmonary Disease (COPD) is a heterogeneous lung condition causing persistent, progressive airflow obstruction. It is the most common disease-specific cause of adult emergency hospital admissions in Ireland1.
Virtual wards (VW) are a promising solution to optimize care for COPD patients 2. The VW aligns with the Slaintecare vision of delivering one universal health service, providing right care, in the right place, at the right time3 for COPD patients.
Approach
This study explores the feasibility and effectiveness of a COPD-VW pathway, expanding the existing Outreach service to include remote patient monitoring for acute exacerbation via MyPatientSpace (MPS). MPS is a platform designed to facilitate communication and engagement between patients and healthcare providers. It allows patients to record their vital signs, engage in self management education, manage their symptoms and access specialised respiratory care throughout the episode of care. The VW MDT provides comprehensive patient care.
A focus group allowed us directly engage with COPD patients for a deeper understanding of their experiences, challenges, and expectations regarding digital health solutions. As one participant remarked, “The technology I’d manage but being able to be in my garden in the sunshine would be amazing”. This collaborative approach ensured that this new service was not only clinically effective but also user-friendly and relevant. Another participant in the group commented, “all about your condition is spoken out loud for everyone to hear” following a recent Accident and Emergency presentation, “to share our stories, helps you see these problems for us” which in turn allows practical solutions.
Results
The feedback on usability has moulded the design for more intuitive interfaces, enhancing patient adherence and engagement. In a recent mHealth App Usability Questionnaire offered within MPS, a respondent scored 7/10 for “The information in the app was well organized, so I could easily find the information I needed.”

The COPD-VW has provided 73 care episodes since launching- April 2024. The average length of stay (LOS) is 6.06 days, 57.4% improvement on LOS compared to the national average 5 . The HIPE data report (2024) estimates costings €8179 per COPD hospital stay. This pilot to date has saved 500.8 days: an estimated €550,000 .

Implications
Findings from this study will provide valuable insights into the potential benefits of a COPD VW and inform future efforts to scale and embed this innovative care model.
Providing patients with feedback opportunities within a care package empowers them to actively participate in their treatment, ensuring that care is tailored holistically to their needs and preferences.

Background:
The integration of digital solutions is a cornerstone of modern integrated care, enabling enhanced coordination, communication, and personalized care across health systems. Digital health innovations are increasingly recognized as crucial for improving the efficiency and quality of care delivery, reducing fragmentation, and empowering patients to take an active role in managing their health (1). The International Foundation for Integrated Care (IFIC) emphasizes the significance of digital solutions in pillar 7 of the nine pillars of integrated care.
The need for structured, effective data management frameworks is underscored by the complexity of modern health systems, where digital solutions must comply with evolving data protection laws such as the General Data Protection Regulation (GDPR) and emerging requirements like the AI Act. Without robust data governance, these systems face challenges in ensuring privacy, security, and ethical data use while striving to achieve integrated care goals.
Approach:
The "Integrating Data in Integrated Care" (IDIC) methodology, developed during the EU funded ValueCare Project (https://projectvaluecare.eu/), responds to these challenges, offering a structured reference model for data governance that aligns with European legislation.
The IDIC methodology is organized around the data life cycle of digital health projects, addressing the specific data management needs of Integrated Healthcare systems (IHC).
The IDIC methodology responds to two major challenges:
1. Privacy, ethical, and legal requirements: Ensuring GDPR compliance, defining clear roles for data governance, safeguarding against bias, and implementing privacy-by-design principles.
2. Patient and technology-centered challenges: Addressing data fragmentation, enhancing data quality, and empowering patients by giving them control over their data, all of which are critical to the success of digital health solutions.
IDIC organizes data management into two core categories:
1. Project Design, Dissemination, and Knowledge Data: Including co-design data from focus groups; dissemination and communication data, including databases with stakeholders’ details and knowledge produced during the project (i.e. intervention models, algorithms).
2. Patient Data in IHC Pilots: Including patient personal data (i.e demographic data gathered during recruiting phases), medical devices data (collected from monitoring devices), wellbeing data from personal devices (pedometers, apps, etc.)., interaction data (self-input data, interactions with chatbots, preferences, etc.), implementation data (record keeping, appointments, coordination meetings, etc).
For each category, the methodology emphasizes:
• Data size and format;
• Storage and backup strategies;
• Retrospective or prospective datasets organisation;
• Different roles of individuals and organisations involved in data management;
• Compliance with the FAIR (Findable, Accessible, Interoperable, Reusable) principles;
• Strategies for consent, data sharing and multi-center pilot implementation;
• Ethical and legal issues;
• Long term preservation of data;
Results and implications:
The IDIC framework provides a replicable, GDPR-compliant approach for data management in IHC projects. IDIC ensures that patient rights are preserved while supporting the deployment of digital solutions, while promoting the IHC agenda. IDIC offers a valuable tool for the digital transformation of health systems, aligning with the broader goal of integrating care through advanced data governance practices.

References:
1. Colnar S, et al. Digital transformation of integrated care: Literature review and research agenda. IFAC-PapersOnLine. 2020;53(2):16890-5.

Background: There is a growing international dialogue surrounding improving public services by shifting to an integrated health and social care approach. A key aspects of advancing integrated care is to share assessments, diagnostics and care plans, between health and social care systems. Shared records can improve the continuum of care, and care coordination while enhancing a patient centred-approach. This study seeks to understand data-sharing practices across health and social care and barriers to the integration of data systems.

Approach: Qualitative interviews were designed to map data-sharing practices in integrated health and social care services in the Sydney metropolitan and analysed in alignment with the Wodchis Policy Supports Framework.

Results: 27 participants from 25 health and social care services were interviewed. Social care organisations reported having less internal technology support compared with health-led organisations. ICT data-sharing practices reported to be limited. Barriers to data-sharing include the ability to meet data security, trust in government to safely handle consumer data, lack of interoperability, and ICT support. Facilitators to data-sharing are partnerships across sectors, and providers’ flexibility, and innovative ways of capturing data.

Implications: Data-sharing challenges in health and social care services in Sydney exists. Increasing advocacy and improving information technology functionally, interoperability and infrastructure, as well as data-sharing agreements across sectors can increase integrated information sharing.

Keywords: Health and social care, data sharing, agreements, electronic records

The ATENTO project embodies a forward-thinking approach in reducing health disparities through digital solutions, centered within the Local Health Unit (ULS) São José, Lisbon. The initiative spans a complex, multicultural service area, comprising seven hospitals, catering to over 1 million people annually. The region’s distinctive demographic profile includes a foreign resident population of over 30%, with communities from Brazil, Nepal, Bangladesh, and Africa, and 10–18% populated by French and Italian residents. This cultural diversity presents unique challenges in delivering equitable healthcare services.
The National Health Service (SNS) of Portugal guarantees universal healthcare access, but disparities remain, particularly in underserved communities. ATENTO aims to bridge these gaps using certified telehealth technologies, enhancing service delivery for diverse patient populations. The project emphasizes integrated telehealth services to increase accessibility and improve the quality of care across ULS São José.
Project Approach: The ATENTO initiative encompasses several core strategies: Continuous Monitoring of impact indicators to assess effectiveness. Training Programs to develop health professionals’ telehealth competencies and cultural awareness. System Integration to align with existing healthcare platforms, ensuring coordinated patient care.
Patient Engagement efforts to enhance health literacy and promote self-management. Financial Sustainability models for long-term viability. Compliance with national and European regulations for ethical service delivery. Designed collaboratively with patients, caregivers, and community representatives, the project tailors its services to meet the specific needs of its population.

Key Results: Since its launch in 2023, ATENTO has demonstrated significant progress:
Patient Outreach: 851 patients have accessed telehealth services.
Medical Devices: 792 implantable devices have been deployed for remote monitoring.
Cardiac Rehabilitation: 15 patients completed rehabilitation programs, and 13 participated in educational sessions.
Education on Syncope Management: Provided to 5 patients.
Respiratory Care: 14 patients with respiratory failure, COPD, or pulmonary fibrosis received telemonitoring.
Support for Neurological Conditions: 2 ALS patients were managed remotely.
The project aims to expand by 2025, targeting 2,800 patients, implementing biosignal monitoring for 300 individuals, deploying 1,500 additional devices, and enhancing data collection with 1,000 assessment forms.

Implications: ATENTO’s success illustrates the potential of telehealth in tackling health inequalities within urban, multicultural settings. Key insights include:

Co-Design with Communities: Ensures culturally relevant care and improved patient acceptance.
Ongoing Professional Development: Enhances the capability to address diverse healthcare needs.
Seamless System Integration: Enhances care coordination and patient outcomes.
Scalability:Provides a model adaptable to similar regions facing health disparities.
Next Steps: Looking forward, the ATENTO project plans to:

Scale the Model to other regions with significant health disparities.
Refine Patient Engagement strategies to boost participation and adherence.
Enhance Data Analytics capabilities to inform decision-making and personalize care.
Build Strategic Partnerships to sustain financial and resource-sharing efforts.
Conclusion: The ATENTO project is a powerful example of how integrated telehealth services can address structural health disparities in diverse populations. It showcases the role of telehealth in promoting equity and inclusion, aligning with the broader theme of "Inclusive Health: Integrated Care to Reduce Inequality." The project’s success underscores the potential of such initiatives in driving systemic change, contributing valuable lessons for the future of integrated care.

Background:
As in many Western countries, a combination of population aging and workforce shortages challenges the current and future ability to meet health and social care needs in the Netherlands. These issues typify the wicked problems that local and regional cross-sectoral partnerships - a type of purpose-oriented network - aim to address. However, there is limited empirical insight into how such partnerships can be classified or how effective they are in achieving their (quintuple aim) goals, depending on their strategies (e.g., governance form, leadership, target group involvement, and resource availability) and context. This study aims to address key gaps in previous research through a large sample size, validated measurement methods, and state-of-the-art data analysis.

Approach:
Since Q4 2023, a yearly survey and benchmarking cycle has been conducted among network managers. The survey applies a clear definition of cross-sectoral partnerships for health and well-being and incorporates validated measurement instruments for effectiveness and its potential antecedents. The 2024 survey round includes an additional short survey for network partners to gain more refined insights into the structure and effectiveness of a subset of partnerships. The survey data have been—or will be—analyzed using social network analysis (SNA), latent-class analysis (LCA), qualitative comparative analysis (QCA), and machine learning (CatBoost). A report with individual and aggregate partnership scores is shared with all participating network managers.

Results:
In 2023, 103 partnerships responded to the survey. Preliminary findings (as of 15 November 2024) from QCA and CatBoost analyses suggest that effective leadership combined with high partner trust is particularly associated with substantive interorganizational partnership effectiveness. Additionally, LCA results indicate that partnerships can be divided into two classes: those likely to have implemented network-administrative steps (e.g., alignment of payment incentives, compliance with competition rules, and changes in service delivery among partnering organizations) and those less likely to have done so. These steps are generally considered critical for achieving structural integration and impact. Results from the 2024 survey round are being collected and will be analyzed in Q1 2025.

Implications:
Methodological limitations in identifying classes and antecedents of cross-sectoral partnership effectiveness were partially addressed. However, ongoing and refined analyses are required to validate the initial findings on the importance of leadership and trust. The 2024 data collection offers the opportunity to deepen insights by including longitudinal and multi-level data (e.g., partner-level input). Our presentation will illustrate and stimulate discussion on the possibilities and challenges of establishing a structured, country-level approach for collective learning and transferring lessons about the antecedents of effectiveness across regions. This approach could benefit practice, policymaking, and science in health policy, integrated care, and organization/management.

Digital tools as a force multiplier: Case example Project Lyreen.

Aim To describe and discuss the increased capacity of the small clinical team and workflow flexibility offered through using the Project Lyreen digital platform.
Introduction/ Background:
The Response for Vulnerable People (RVP) team supports new migrants, homeless people and excluded groups across over 250+ distinct locations in the Dublin Midland region of Ireland.
Supporting thousands of distributed migrants that are new to the country with limited access to primary care required a change of approach. Through remote working a small clinical workforce is supported by a larger social care team who act as the eye’s ears and hands of the clinicians.
Methodology:
Project Lyreen is layered secure suite of tools that is entirely device agnostic and comprises a cloud based EHR, cloud based threaded communications layer and cloud-based data aggregation. This empowers enhanced care and support delivery to migrants and other excluded groups both remotely and face to face in non-traditional healthcare settings in challenging circumstances.
Project Lyreen Platform digital stack layers
EHR:
Provides distributed remote multi-viewer access to clinical records for clinicians AND patients which equates to safer more effective and efficient care. Care as usual in Ireland is provided via paper records which are single viewer face to face only.
Communications layer: Entire multi-disciplinary team in threaded secure channel for advice and care planning means safer more effective and efficient care.
Standard Care in Ireland is provided and co-ordinated via face to face telephone or email, rarely real time live dialogue including image/video. Our solution includes telehealth as standard for both consultations and conferencing between the team and this is supported by secure threaded messages.
Data Aggregation:
Tools provide the ability to collect data using online/offline forms and aggregate into a secure shared filespace as well as the EHR. Files and forms can be securely shared and edited online/offline. Care as usual equates to paper based forms.
4. Cloud Computing: The entire service is device agnostic, access to layers is through web interface SAS (software as service ) rather than local installations. (care as usual = best comparator -local installed per machine licence no access outside of windows)
Main results and findings:
Initial findings of an evaluation undertake by Professor Martin Curley (Maynooth IVI) suggest platform performs a full 10x shift left in multiplying the capability of a small group of clinicians in that it allows a small(er) than would otherwise needed team of clinicians (n=14) to support a larger than typical group of patients with complex needs (n=15000). Further detailed data on this will be presented at the conference This platform. enhances access to health services for groups that would otherwise be excluded from health care as they cannot access mainstream care services for a range of reasons.
Conclusions:
Project Lyreen is undergoing full testing and evaluation at a larger scale and in different clinical contexts (200,000 patients and acute/community settings). It is proposed to be scaled as a complete digital health spine for Ireland.