A sustainable multidisciplinary model for personalised care for frail older people, using artificial intelligence and the next generation medical records

Digi-FrailCare targets digitisation and the use of digitised health data to improve health services for older people at risk of or with frailty. Frailty refers to age-related physical debility; a complex condition characterised by a cumulative decline across multiple physiological systems and increasing vulnerability to adverse health outcomes and death. Sustainable health services for frail older people are highly needed.  

The project aims to develop and pilot a machine learning based EMR multidisciplinary primary health care model for preventing frailty and adverse events, and to synthesize findings for recommendations at a local, national and international basis. The project will impact future multidisciplinary work models for frailty to improve health and function in older people, for the sake of improved and sustainable future health care services.  

Digi-FrailCare will use a holistic approach and implement new knowledge on the interplay between risk factors for deterioration in health and function, including oral health and nutrition, general health, disease and function, polypharmacy, and cognition. We will build multidimensional risk assessment and prediction models for frailty using health data from large epidemiological studies, including the HUNT studies, and will prepare them for implementation and validation in HP, and for use as real-time digital multidisciplinary tools. The multidisciplinary service will be implemented in Trondheim municipality.

More system knowledge is required about which type of information is important and how technical solutions fit how health care personnel collaborate in providing coordinated, proactive care and effective services. Therefore, we will assess human and non-human actors' impact when implementing HP, and which infrastructures, systems, and groups the implementation is dependent on. Results will be synthesised and recommendations for further implementation will be developed. However, just introducing the system without also developing the services using the system may lead to merely a digitalising of an existing offline workflow without facilitating new and more sustainable ways of working. Thus, we approach this change rather as digitalisation, which also changes practices and users in the sociotechnical network.  

Digi-FrailCare is performed by a strong multidisciplinary team from three faculties at NTNU, supported by national and international collaborating partners. Three PhDs and one postdoc will work together with an interdisciplinary supervision project team from three faculties and departments to tackle the grand challenges of frailty. This will be done on a medical (MH), a technical (IE), and a societal (HF) expertise level from the three respective PhDs and their faculty affiliation, with an interdisciplinary focused postdoc to integrate the findings across disciplines.  

External collaborators

• Marit Kolberg: Center for Oral Health Services and Research Mid-Norway (TkMidt) 
• Ingvild Paur: Norwegian Advisory Unit on Disease-Related Undernutrition (NKSU)