LIFE LONG-MONITORING OF FRAIL PATIENTS WITH CHRONIC DISEASES IN VENETO REGION
Veneto Region recruits 166 elderly frail patients with more chronic diseases and randomize them in a control and an intervention group with a 1:1 ratio. A group of general practitioners of 7 Local Health Authorities have been involved in this pilot study as the health professionals in charge of patients follow-up during the 12 months follow-up.
Self monitoring
Remote monitoring of chronic patients integrates a pre-existing telecare service for detection of emergency situations at patient home with a new telemonitoring system that connects the patient with his general practitioner by the intermediation of a Regional eHealth centre in charge of the central management of patient data.
The telemonitoring system
The following figure schematizes the telemonitoring system architecture:
The patient is equipped at his home with a Personal Health System, composed of a personal alarms device for 24/7 real time emergency detection and biomedical devices for clinical data collection. According to his diseases, the patient can have a wristclinic device to measure pulse-oxymetry, heart rate, ECG and blood pressure (if he has COPD and heart failure) and/or a wireless weight scale (if he has heart failure) and/or a POCT glucometer (if he has diabetes). The system is completed by a home gateway for data transmission.
According to the personal monitoring program, scheduled by the GP, the patient measures his data that are automatically transmitted by the gateway to the server located in a Regional eHealth centre, where data are processed in order to recognize potential alarm values, according to the threshold set by the GP for that patient.
In the eHealth centre, a group of trained operators can access the telemonitoring web-portal where the patient personal electronic profile is continuosly and real time updated by the transmitted data flow.
At any time the same information are available also for the GP for that patient, simply accessing the dedicated web portal with his own credentials.
The eHealth centre
The role of eHealth centre is of fundamental importance, as it is in charge of the first processing of all data transmitted from patient home. In case of parameters out of range, the operator calls the patient verifying the correct data measuring and if the alarm is real, he alerts the GP, or even the ER department.
The eHealth centre plays an important social role, as it is also the collector of the telecare alarms, triggered by the patient with the specific device, in case of emergency situation (sudden worsening of symptoms or accident in the home). The centre operators also manage these occurrences, putting in touch the patient with the proper reference persons, such as the ER department, the Social Services or directly his family. In addition, the operators are in charge of making scheduled control calls to monitor patient life conditions and quality of life and check for COPD patients the disease symptoms through monthly administration of the COPD Assessment Test (CAT).
Expected outcomes
The telemedicine application, thanks to its double clinical and social nature, is expected to improve the management of those patients with chronic diseases who also have strong limitations in their everyday life because of their clinical conditions. The resulting benefits are measured in terms of reducted access to health facilities (hospital admissions, bed-days, specialistic, GP and ER visits), improvement of quality of life and reduction of anxiety about health conditions. From the economic and organization side, telemonitoring should contribute to improve the chronic and frail patients management, to re-organize the healthcare resources in a more efficient way and to limit their expenditure. Particular attention is addressed to reach the acceptability of telemonitoring by patients and health professionals.
Other cluster of Veneto Region: Cluster 2, Cluster 5, Cluster 7, Cluster 8