Transforming Chronic Disease Care with Digital Solutions
Across Europe, healthcare systems face increasing pressure due to an aging population, rising prevalence of chronic diseases, and the growing need for accessible follow-up care. Conditions such as epilepsy or age-related physical deterioration require continuous monitoring, coordination, and communication between patients, caregivers, and healthcare professionals. Yet, traditional care pathways often struggle to provide the frequency, personalization, and agility these cases demand.
In this context, ESFERA, a digital health platform co-created within the HealthChain project by the Servicio Murciano de Salud (SMS), Evidenze, and Aicrum, represents a transformative response. Designed as a comprehensive ecosystem for patient–professional collaboration, ESFERA provides personalized monitoring, digital communication, and structured follow-up tools that enhance decision-making and improve self-management capabilities of patients.
Through tailored modules, including dashboards, symptom calendars, teleconsultation capabilities, audiovisual educational resources, and customizable PROMs/PREMs, ESFERA not only optimizes continuity of care but also empowers users, reduces workload for clinicians, and minimizes system inefficiencies.
Addressing the Challenges: A Collaborative Digital Health Solution
Chronic patients often face fragmented communication, limited support tools, and insufficient visibility of their daily symptoms or treatment adherence. Professionals, on the other hand, encounter challenges such as:
- Overloaded primary care appointments
- Lack of real-time data about patients’ evolution
- Difficulties in monitoring treatment adherence
- Insufficient coordination with relatives and caregivers
The benefits are for both patients and healthcare professionals.
For patients:
ESFERA directly addresses these issues through a multi-actor digital architecture that interconnects professionals, patients, caregivers, and administrative staff. Its customizable “circles” allow health teams to group users by condition, manage specific content, and automate monitoring workflows.
- Better control of symptoms and treatments
- Increased understanding of their condition
- Direct and simplified communication channels
- Enhanced autonomy thanks to visual dashboards and reminders
For healthcare professionals
- Immediate overview of patient or group status
- Fewer unnecessary consultations thanks to remote follow-up
- Better prioritization based on alerts, symptoms, or changes
- More efficient time and case management
By aligning with EU digital transition principles and health equity goals, ESFERA contributes to improving healthcare delivery in a scalable and sustainable manner.
Direct Collaboration with International Experts: Enriching the Digital Health Innovation Process
The development of ESFERA has been grounded in co-creation, a central methodology of the HealthChain project. Through meetings with all consortium partners and healthcare professionals, the Murcia region has gained meaningful perspectives on:
- Clinical expertise and real-world use cases: through co-creation meetings with SMS healthcare professionals.
- Usability and daily life needs: involving patients and caregivers in decision-making.
- Translation of clinical workflows into adaptable digital tools: having real communication between healthcare professionals and the development team.
- Telemedicine, chronic care, and digital integration: external expertise shared by European partners.
This multi-stakeholder collaboration ensures the platform addresses real clinical challenges while remaining adaptable across different contexts and health systems. Additionally, ESFERA builds upon CÍRCULO, a previously implemented SMS platform with more than three years of operational experience, ensuring reliability, evidence-based evolution, and patient-centered design.
Pilot Execution and Key Results
The ESFERA pilot, carried out between July and December 2025, has provided a real opportunity to observe how a digital solution can transform communication and patient follow‑up within the Servicio Murciano de Salud (SMS).
Through two use cases, Epilepsy and Oncology, it has been possible to see how different profiles interacted naturally and progressively with the platform: healthcare professionals, patients, relatives or caregivers, administrators, and external professionals.
Participation in the pilot and early observations reflect how ESFERA was embraced across the care ecosystem. A total of 32 participants became actively involved in the pilot, representing all profiles:
- Epilepsy: 14 users (1 administrator, 1 case manager, 1 healthcare professional, 6 patients, and 5 relatives).
- Oncology: 18 users (1 administrator, 1 case manager, 3 healthcare professionals, and 13 patients).
Effectiveness of Digital Health Solutions
The adoption of digital health tools was instrumental in enhancing patient experiences. ESFERA demonstrates effectiveness in several strategic areas:
- Treatment adherence improvement: the system enhances adherence to medication and rehabilitation routines by incorporating alerts, simplified tracking, and educational support.
- Reduction of healthcare saturation: remote monitoring avoids unnecessary consultations and emergency visits.
- Increased system efficiency: better prioritization, real-time data, and contextual dashboards accelerate clinical decision-making.
- Patient empowerment: patients adopt a more active role in managing their conditions.
Lessons Learned
The pilot provided essential learnings that will guide the next phase of ESFERA’s evolution and support smoother implementation in future deployments.
Multidisciplinary collaboration emerged as a key success factor, with professionals from hospitals, primary care, and pharmacy services showing strong interest in tools that support seamless collaboration with patients; ESFERA’s design benefited significantly from these diverse perspectives, underscoring the value of cross-sector input.
Furthermore, the pilot demonstrated that innovation within public healthcare is achievable, showing that public health organizations can successfully adopt agile methodologies and integrate digital solutions when coordination, governance, and inter-team collaboration are strong.
Finally, sustained engagement was identified as a cornerstone of long-term success, as both healthcare professionals and patients recognized clear value in maintaining and expanding ESFERA beyond the pilot phase, particularly due to improved treatment monitoring, more active communication, and greater precision in follow-up care.
Future Outlook: Scaling the Digital Health Solution
ESFERA is strategically positioned to expand across regions, hospitals, and other EU healthcare systems. Its modular and interoperable architecture ensures compatibility with existing HIS solutions and facilitates rapid deployment.
Strategic future steps include:
- Expansion to additional chronic conditions and specialties.
- Reinforced interoperability with corporate health systems.
- Continuous improvement of functionalities.
- Increased collaboration with regional, national, and EU healthcare authorities.
Disclaimer: Co-funded by the European Union. Views and opinions expressed are however those of the author(s) only and do not necessarily reflect those of the European Union or European Innovation Council and SMEs Executive Agency (EISMEA). Neither the European Union nor the granting authority can be held responsible for them.HealthChain project is funded by the European Union. Views and opinions expressed are however those of the author(s) only and do not necessarily reflect those of the European Union or European Innovation Council and SMEs Executive Agency (EISMEA). Neither the European Union nor the granting authority can be held responsible for them.
