DALLA TELEMEDICINA ALL’HOME
MONITORING- PRIMARY CARE
WORLDWIDE 1997 2010
FR ANC O NAC C AR ELLA, FAB IO IAC HETTI
LEILEI S UN, MA JUN, ZHANG FENG
R OMANO ZANNOLI, C LAUDIO LAMB ER TI
C R IS TINA FELIC ANI, G IOVANNINA LEPER A,
ELVIR A MOC C IA, S TEFANO S DR ING OLA
MAR ANG A, MAR IA B OIANI
TWO S PEC IAL IS S UE S OF THE
INTER NATIONAL
“JOUR NA L OF THE MEDITERR A NEA N
S OC IETY OF PA C ING A ND
ELEC TROPHYS IOLOG Y “.
Number ONE
VOL 2 JUNE 2007
932 S UB S C R IB E R S IN US , E UR OPE AND
IN THE ME DITE R R ANEAN AR E A
QUOTED IN C UR R E NT C ONTE NTS AND
1. OVERVIEW OF INTERNATIONAL TELEMEDICINE
EXPERIENCES AND INTERNET BASED HEALTH CARE
SERVICES. ACTUAL STATUS AND PERSPECTIVES
“FR OM TELEMEDIC INE A ND
TELEC A R DIOLOG Y TO WEB B A S ED
HEA LTH C A R E S YS TEMS . A G ENERA L
OVERVIEW OF INTER NA TIONA L
EXPER IENC ES ”
2. TELEMEDICINE EXPERIENCES AND
TECHNOLOGIES IMPLEMENTATION IN
DIFFERENT MEDICAL SPECIALTIES
Iachetti Fabio**, Naccarella Franco **,Naccarelli G erald#,
S cher David ## Leilei S un *, Felicani C ris tina**&, Lepera
G iovannina **, Wang Ang ela $,
** C ardiolog ia AUS L, B olog na
#C ardiolog y Department Hers hey Penn S tate Univers ity,
Hers hey, PA US
## C ardiac Electrophys iolog y As s ociated C ardiolog is ts
Harris burg , PA US
& Is tituto di C linica Medica, B olog na
$ Phys ician and expert in Wes tern Drug Therapy; Univers ity
of B olog na, C UP 2000, Univers ity of B ejing
*Univers ita deg li s tudi di Perug ia
3. TELEMEDICINE: TECHNOLOGICAL DEVELOPMENTS,
LEGAL ASPECTS AND COST BENEFIT ANALYSIS
Iachetti Fabio**
Naccarella Franco **,
Naccarelli G erald#, S cher David ##
Felicani C ris tina**&, Lepera G iovannina **, Wang Ang ela $,
Proietti K aty*
** C ardiolog ia AUS L, B olog na
#C ardiolog y Department Hers hey Penn S tate Univers ity,
Hers hey, PA US
## C ardiac Electrophys iolog y As s ociated C ardiolog is ts
Harris burg , PA US
& Is tituto di C linica Medica, B olog na
$ Phys ician and expert in Wes tern Drug Therapy; Univers ity
of B olog na, C UP 2000, Univers ity of B ejing
* Eng ineer and Quality Manag er S ADEL S .p.A.
C as telmag g iore (B O) www.s adel.it
4. REMOTE MONITORING SYSTEMS OF IMPLANTED
DEVICES
CRITICAL EVALUATION IN US, EUROPE AND ITALY Iachetti Fabio** Naccarella Franco **, Naccarelli G erald #, S cher David ##,
Is rael W. C ars ten & S tellbrink C . &&&
Wang Ang ela $, Proietti K aty *
Pezzotta Ales s andra §
** C ardiolog ia AUS L, B olog na
#C ardiolog y Department Hers hey Penn S tate Univers ity,
Hers hey, PA US
## C ardiac Electrophys iolog y As s ociated C ardiolog is ts
Harris burg , PA US
& C ardiolog y Electrophys iolog y and Pacing . Divis ion of
C ardiolog y
JW G oethe Univers ity. Frankfurt G ermany
MESPE Number ONE - VOL 2 JUNE 2007
INTR ODUC TION
MEDIC AL AS PEC TS
Prof. Enrico Adornato. Pres ident of MES PE
AS S ES S MENT AND IMPLE MENTATION
AS PE C TS
E ng . C arlo Mambretti, E ng . Luig i Mazzei
As s obiomedica Italy
TEC HNIC AL AS PEC TS
Prof. R OMANO ZANNOLI, Eng . C LAUDIO LAMB ER TI .
C hair of Phys ics , C ardiolog y Department Univers ity of
B olog na,
TELEMEDICINA E SANITA' MILITARE
TE LEMEDIC INE - TE LEC AR DIOLOG Y
FR OM MILITAR Y TO C IVILIAN
APPLIC ATIONS . THE C E LIO HOS PITAL IN
R OME INTER NATIONAL EXPER IENC E S .
ITAR G en. M. Anaclerio, ITAR Lt. C ol. E .
C ucuzza and co-workers
G en. Michele Anaclerio
C ons ig liere del Minis tro della Difes a per
la S anità Militare
TELEMEDICINA E SANITA' MILITARE
TELEMEDICINA E SANITA' MILITARE
• L’utilizzo dello s trumento della Telemedicina da
parte della nos tre Forze Armate inizia nel 1996
dopo l’ins ediamento s ul territorio B os niaco del
conting ente militare italiano inviato in s eg uito
all’applicazione deg li accordi di pace di Dayton.
• • S i ravvis ò all’epoca, infatti, la neces s ità di
g arantire un s upporto s anitario pluris pecialis tico
non s olo alle truppe pres enti in quel teatro ma
anche alla popolazione civile in cons iderazione
della marcata connotazione umanitaria di quella
mis s ione.
TELEMEDICINA E SANITA' MILITARE
TELEMEDICINA E SANITA' MILITARE
• Lo s copo era quello di utilizzare nel modo
mig liore le ris ors e limitate di pers onale
medico ad elevata s pecializzazione e nel
contempo di evitarne l’is olamento
profes s ionale una volta collocati in Teatro.
• In g iocoforza utilizzare il percors o
s atellitare che era l’unica via tras mis s iva
percorribile vis to lo s tato di dis truzione
infras trutturale in cui vers ava il Paes e.
• TELEMEDICINA E SANITA' MILITARE
TELEMEDICINA E SANITA' MILITARE
• Dal settembre 1996 al 31 ottobre 2006 sono
state effettuate
• · 11025 ore di sessioni satellitari (test,
prove, casi, ecc.); di cui
• · 6284 ore dedicate ai soli casi clinici;
con
• · 1531 ore dedicate a teleconsulti
• · 2851 dedicate a teleconsulti; di cui
• · 1509 i militari trattati (diagnosi e
terapia); e
• · 1342 i civili trattati (diagnosi e
INTERNATIONAL EXPERIENCES
• TE LE ME DIC INE: A R E VIEW
OF INTE R NATIONAL
E XPE R IENC E S .
TE C HNOLOG IE S , ME DIC AL
AS PE C TS AND
PE R S PE C TIVE S .
• Dr. Fabio Iachetti and co-workers ,
cons ulting G roup on information and
communication technolog ies in medicine
INTERNATIONAL EXPERIENCES
VA home-telehealth for diabetics
• The deployment of advanced
technolog ies will minimize the
barriers of dis tance and
g eog raphy, to enhance acces s
and facilitate the delivery of
integ rated health care.
• This will s upport and enhance the
g oals of the US federal Healthy
People 2010 initiative. (9-10)
VA home-telehealth for diabetics
• One of the mos t important networks of
telemedicine in the US is s upported, as
previous ly s tated, by the VA hos pitals network,
which is active in many medical s pecialties and
with the extreme s ucces s , for example, in the
care of diabetic patients . (11-16)
• In fact, the objectives of the VA home-telehealth
for diabetics were to as s es s healthcare us e
among veterans with diabetes mellitus (DM),
enrolled in a Department of Veterans Affairs (VA)
C are C oordination Home Telehealth (C C HT)
prog ram during 24 months
• and to compare this utilization with the s ervice
us e of a comparis on g roup of veterans with DM,
VA home-telehealth for diabetics
• The cos t-benefit balance will chang e,
when it becomes pos s ible to us e
devices that are owned by patients for
everyday us e, rather than ins talling
s pecial-purpos e devices for
telemedicine.
• Technolog y and communications
capabilities are driven mainly by
market factors other than us es for
health care.
INTERNATIONAL EXPERIENCES
INTERNATIONAL EXPERIENCES
INTERNATIONAL EXPERIENCES
Figure 1: States which Provide Medicaid Reimbursement
for Home Telemedicine, mid-1998 [Audrey Kinsella, 1998]
Figure 2: Snapshot of potential sources for reimbursement for home
telemedicine.
INTERNATIONAL EXPERIENCES
INTERNATIONAL EXPERIENCES
INTERNATIONAL EXPERIENCES: SCANDINAVIAN
AREA
• Under the EU " Telematics in Health C are"
prog ramme a s urvey has been made of various
telematic applications in Europe (s uch as the
monitoring of preg nant women in home
conditions (DFM), the computer-aided health
promotion of g rowing young s ters (E ZOOT),
s upport for the acquis ition of data on dis abled
pers ons (HANDYNET),
• the technolog y initiative for dis abled and elderly
people (TIDE), the increas e of s ocial s upport
(R AC E), and the s timulating of public debate
between urban populations (ETM)).
• The finding s are reported in a book publis hed
las t year (G ott, 1995).
Figure 6. Telemedicine connections of Åland
INTERNATIONAL EXPERIENCES: SCANDINAVIAN
AREA
• The E U funded telemedicine development
projects in Finland in 1995, at leas t the
joint project involving the C ity of Turku
health care and Turku Univers ity C entral
Hos pital (IS AR -T), and the TE R VE project
in the North K arelia Hos pital Dis trict.
• The E U has als o awarded funds for a joint
project taking in the is land province of
Åland, the S tockholm archipelag o, and the
is lands of G otland and B ornholm (the Ö
Project).
INTERNATIONAL EXPERIENCES: SCANDINAVIAN
AREA
• There are a number of journals on the
s ubject, s uch as the Journal of
Telemedicine and Telecare, the
Telemedicine Journal, Telemedicine Today,
the Healthcare Telecom R eport, and EmedNews.
• The number of s cientific articles on the
s ubject has rocketed in a few years . In
1993, only 22 articles were found under the
s earch word " telemedicine" in the Medline
databas e, as ag ains t a total of 134 already
Figure 1. Telemedicine connecti ons of Helsinki University Central
Hospital
Figure 2. Telemedicine connections of Varsinais-Suomi
Hospital District
Figure 3. Telemedicine connections of Pirkanmaa Hospital
District
Figure 4. Telemedicine connections of Pohjois-Savo Hospital
District
TELEMEDICINE IN ICELAND
• The firs t telemedicine project in Iceland
s tarted in 1993 with the s ending of X-ray
pictures from the s mall hos pital in the
Wes tman Is lands off the s outh coas t to
Lands pítali Univers ity Hos pital.
• S ince then, s ix hos pitals have been
connected to Lands pítali in R eykjavík and
Akureyri Hos pital in the north. The Minis try
of Health and S ocial S ecurity has is s ued a
plan for routine telemedicine s ervice as an
integ ral part of the health care s ervices .
• S IMILAR TO OUR HOPIS TALS NETWOR K
TELEMEDICINE IN ICELAND
• In many E uropean countries ,
telemedicine has been
developed in areas with larg e
rural areas without adequate
hos pital facilities and s cattered
populations and, to a les s er
deg ree, the problem of
dis tances was taken into
TELEMEDICINE IN ICELAND
• For the time being , only radiolog ical
s ervices and educational meeting s are
provided on a routine bas is , but s eparate
telemedicine projects include ultras ound
obs tetrical examinations , ps ychiatric
cons ultations , emerg ency medicine for
thos e at s ea, and patholog y us ing imag e
and text web tools ,
• as well as teaching g raduate and
educational s eminars throug h
videoconferences .
• Telemedicine is s een as an effort towards
TELEMEDICINE IN ICELAND
• Telemedicine have a role for
Icelandic healthcare and may
prove to be very us eful.
• There are a number of factors
who need preparation before
the implementation of a
Telemedicine s ervice.
•
ICT IMPLEMENTATION 2001: TOP 20 COUNTRIES
ICT IMPLEMENTATION 2002: TOP 10 COUNTRIES
ITU has just released its new s tatis tics on global broadband penetration per 100
inhabitants as of 1 January 2006. Iceland has taken over as this year's leader from
Korea with Netherlands, D enmark and Hong Kong, C hina rounding out the top five.
• The mos t advanced telemedicine
countries in Europe are Norway,
S weden and France. Althoug h Finland
was the firs t Nordic country to apply
telemedicine, in 1969, it was followed
by S weden in 1970 and Norway in
1983.
• Norway has s et up a telemedicine
centre at Troms ö that has helped to
develop telemedicine connections in
OTHER EUROPEAN COUNTRIES: ROMANIA
• S MAR T C AR DS APPLIC ATION FOR
ALZHE IMER DIS E AS E.
• AN EXAMPLE OF K NOW-HOW TR ANS FER
B E TWE EN ITALY AND R OMANIA
• I. Mois il, C . R oman, A. S zekeli, C . Medes an
(“Lucian B lag a” Univers ity of S ibiu,
R omania)
Distant doctors make their rounds via satellite
• Dis tant doctors make their rounds
via s atellite
• S atellite telemedicine s tation
C redits : ES A
• ES A telemedicine technolog y enables s pecialis t phys icians to
perform detailed patient cons ultations from hundreds of kilometres
away.
Hig h-res olution video imag es and data s ig nals s ent via s atellite links
have already made ’’telecons ulting ’’ a routine procedure in one part
of Europe. The Ag ency’’s involvement with s atellite telemedicine
beg an back in 1996, when ES A provided a s atellite communication
s ys tem to link Italian hos pitals with a field hos pital in S arajevo in
B os nia, enabling telecons ultations for both civilian and military
patients – either live videoconferencing or els e ’’offline’’
trans mis s ion of multimedia patient data for later diag nos is .
OTHER EUROPEAN COUNTRIES: ROMANIA
ITALY COLLABORATION
OTHER EUROPEAN COUNTRIES: ROMANIA
ITALY COLLABORATION
• Trin-II vis its a telecenter for " R oma" people in
R omania Ins ide the activities of our IV
Trans national meeting , in R omania, members of
Trin-II vis ited a R oma s ettlement of R oma people,
near Oradea, in a rural area.
• Another experience from Eas tern Europe (35)
tes tifies that IC T information and communication
technolog ies , in the health care s ector, can g row
fas ter and more eas ily in countries with an
underdeveloped health care s ys tem. The paper is
pres enting the recent evolution of e-health
OTHER EUROPEAN COUNTRIES: ROMANIA
ITALY COLLABORATION
OTHER EUROPEAN COUNTRIES: ROMANIA
ITALY COLLABORATION
SHARE OF ICT MARKET IN A DEVELOPING COUNTRY
SHARE OF GLOBAL ICT MARKET 2005
2) EUROPEAN AND ITALIAN SITUATION:
EPIDEMIOLOGICAL DATA
INCREASING NUMBER OF HOSPITAL ADMISSIONS
INCREASING HEALTH CARE COSTS DUE TO AGE
THE METROPOLITAN AREAS EXPERIENCE. BOLOGNA,
LONDON BARCELONA
CULTURAL EVOLUTION OF GENERAL PRACTITIONER
…..DEALING WITH 75% OF CHRONIC DISEASE
PATIENTS
10-15% OF PATIENTS USE INTERNET !!!
WIDE BAND INTERNET
THE BARCELONA EXPERIENCE
THE BARCELONA EXPERIENCE
THE BARCELONA EXPERIENCE
THE LONDON EXPERIENCE
THE LONDON EXPERIENCE
THE LONDON EXPERIENCE
ASSISTENZA DOMICILIARE INTEGRATA
THE FRAGILE OLD PERSON. I CARE CEDAF FORLI 2003-2010
THE FRAGILE OLD PERSON. I CARE CEDAF FORLI 2003-2010
THE FRAGILE OLD PERSON. I CARE CEDAF FORLI 2003-2010
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Fig ure 2: log ical and technolog ical framework of I-C are s ys tem
The technolog ical architecture of I-C are s ys tem keeps the s ame articulation between
the different s ubjects (s ee Fig ure 2) and is bas ed on three main components :
Manag er, for the activities of manag ement org anizations ;
Integ rator, to coordinate and integ rate information flows between Manag er, Field and
other external s ys tems ;
Field, for the activities of the org anizations that s upply s ervices .
I-C are s ys tem is developed us ing J2EE 1.3 platform, the Java-centric environment
univers ally accepted as indus trial s tandard able to warrant hig h levels of reliability,
hardware independence and maintenance.
The conceptual model adopted is a three-tier architecture (s ee Fig ure 3), a principle of
s oftware des ig n that, for reas ons of efficiency, s eparates s oftware proces s es into
layers . In other words it divides the application into areas bas ed on various s tag es or
tas ks in a proces s ; in this cas e:
the pres entation layer (G UI, “Graphic Us er Interface”, the part of the s ys tem that
embodies the pres entation of the objects in the s ys tem to the us er);
the middleware layer (bus ines s log ic, the part of an application prog ram that performs
the required data proces s ing of the bus ines s ; it refers to the routines that perform the
data entry, update, query and report proces s ing , and more s pecifically to the
proces s ing that takes place “behind the s cenes ”);
the backend layer (where the traditional data proces s ing occurs , that includes
databas e and s ervices ).
Figure 3: three-tier architecture, the conceptual model
adopted for I-Care system
THE FRAGILE OLD PERSON. I CARE CEDAF FORLI 2003-2010
• Defence Technology for Health Chronic Obstructive Pulmonary
Disease (DTfH - COPD)
•
Based at: QinetiQ plc Project contact(s): Mr Keith Smith Discipline:
Telecare Project start: April 2000 Project end: March 2002 Type of
project: Patient Care Project website: n/a Project Funder:HM Treasury Capital Modernisation FundProject description:The COPD proof of
concept project is designed to trial 3 separate, but integrated, methods of
home monitoring. 50 patients have been selected from West Surrey Health
Authority. Each patient has a history of acute exacerbations that often lead
to hospital admittance. The aim of the trial is to provide evidence to support
the clinical view that hospital admissions can be reduced by intervening at
an earlier stage during the onset of an exacerbation. COPD is recognised
as both a major cause of winter pressures on the NHS, and of premature
deaths in the UK. It is also the third most common cause of lost working
days through certified illness.
Defence Technology for Health - Chronic Obstructive
Pulmonary Disease (DTfH - COPD)
•
Aims and objectives: 1. To establish remote respiratory monitoring for
patients in the community suffering fom COPD. 2. To utilise a 24-hour call
centre facility (or 9-5 call centre, with out-of-hours support) for data
processing and interpretation. 3. Explore the role of the respiratory nurse
specialist to further support care. Development plans: Further studies are
required to consider: The added value of the daily telephone call from the
virtual nurse combined with remote home monitoring over a less intensive
telephone support. Identification of the predictive variables or combinations
of variables that predispose, or relate to acute escalations in COPD
patients. The clinical and cost effectiveness of using 24-hour NICRAM
monitoring on a larger scale. Which other groups of patients are likely to
make most clinical and cost-effective use of the service.
Results/comments: Hospital admissions had fallen to around half the
anticipated number but because of the small numbers involved this finding
should be treated cautiously. Patients accepted the monitoring and found
the equipment easy to use and the Nestor Healthwatch service reassuring.
They felt that their condition was well managed by the service. The
experience gained through running this project was transferred to the NHS
so that the NHS could continue the service using its own resources.
Defence Technology for Health - Chronic
Obstructive Pulmonary Disease (DTfH COPD)
Defence Technology for Health - Chronic
Obstructive Pulmonary Disease (DTfH - COPD)
Defence Technology for Health - Chronic
Obstructive Pulmonary Disease (DTfH - COPD)
Defence Technology for Health - Chronic
Obstructive Pulmonary Disease (DTfH - COPD)
spirolab III
diagnostic spirometer with oximetry option MiniSpir
Portable USB Spirometer Oxi-Pulse
Finger Oximeter •The second case suffered
from recurrent VT.
•The patient was
defribrillated 14 times.
•Both patients were later
admitted to the hospital and
received an ICD
implantation.
C.G. OUT OF HOSPITAL CARDIAC
ARREST: RECURRENT VT
13° EPISODE OF SVT,
CARDIOVERTED BY AED
CONCLUSIONS 1
• AED can be easily implemented in a
large condominium, if the residents are
willing to take the CPR course and
certificate, in the local 118-emergency
department school.
• A direct telephone connection should
be made available with the local 118emergency department (which is not
yet the case in Bologna) to
simultaneously call for an emergency
ambulance and team.
CONCLUSIONS 2
Many other patients have
been successfully monitored
for 20 minutes, while waiting
for an emergency ambulance.
CA can be promptly and
adequately treated by relatives
and family members, when
AEDs are available close to the
patient’s house.