A multi-tenant clinical trial platform for European healthcare

Twistag built a multi-tenant clinical trial platform for Worthmed, a clinical research organisation based in Portugal serving hospitals and research centres across Europe, compressing protocol design from 12–16 weeks to 6–8 weeks without loosening regulatory compliance or data governance. Clinical teams had been coordinating protocol design, ethics approval, site management and regulatory submission across email, disconnected spreadsheets, paper forms and vendor-specific systems. Twistag modelled the entire trial lifecycle into a normalised PostgreSQL schema, built the interface in Blazor WebAssembly on a .NET Core backend, and made the platform emit and consume FHIR bundles.

Clinical trials are among the most regulated activities in European healthcare. Every study requires protocol design, ethics approval, patient recruitment workflows, data collection governance, and regulatory readiness across INFARMED, EMA and national standards — and those tasks are fragmented across email, disconnected spreadsheets, paper forms and vendor-specific systems. A single trial's design phase consumed months of coordinated work from R&D, compliance, patient services and regulatory teams before patient enrolment even began. Worthmed saw this as a structural market problem rather than an internal one: its customers were losing competitive advantage because they could not move from protocol concept to regulatory submission quickly. Delayed trials mean delayed patient access to new treatments and delayed revenue for sponsors.

Twistag designed the platform as a multi-tenant operating system for clinical research workflows rather than a bolt-on tool, and started with the data. Twistag modelled the entire clinical trial lifecycle — protocol structure, site networks, regulatory templates, audit trails and patient cohorts — into a normalised PostgreSQL schema able to scale across hundreds of concurrent studies.

The frontend is Blazor WebAssembly, which puts C# on both client and server: faster iteration, fewer type mismatches between UI and backend, and a smaller attack surface for healthcare security reviews. The backend runs on .NET Core using gRPC rather than REST for inter-service communication, cutting latency for real-time collaboration and bandwidth when teams build protocols in parallel. FHIR compliance was non-negotiable, so the platform emits and consumes FHIR bundles and patient demographics, observation data and clinical outcomes flow directly between Worthmed and partner hospital EHRs. AWS S3 handles document storage with versioning for audit trails, and role-based access control with cryptographic audit logging makes every action traceable.

Hospital procurement is a product constraint, not a sales problem. Hospitals scrutinise architecture relentlessly before they will run a trial on someone else's platform, so Twistag built to their standards from day one rather than retrofitting for the first security review. When Hospital CUF Descobertas onboarded, they brought real protocols, and that feedback shaped the next three iterations. Twistag validated each feature against actual hospital workflows before generalising it.

Stack: .NET Core, Blazor WebAssembly, PostgreSQL, gRPC, AWS S3, FHIR. Services: AI-native product engineering, AI-ready data platforms, regulated-industry delivery.

Protocol design time compressed from 12–16 weeks to 6–8 weeks. Studies that were blocked waiting for approvals now move, and hospital teams have real-time visibility into regulatory readiness instead of chasing status emails. Worthmed's customers, including multiple top European healthcare organisations, are onboarding because the platform works at hospital scale rather than startup scale. The engagement has scaled from initial MVP into ongoing multi-year product development. Compliance submissions became documentation of what happened rather than reconstruction after the fact, because role-based access control and cryptographic audit logging record every action as it occurs.

When the platform is built for regulation from day one, submission becomes documentation rather than reconstruction work.