Healthcare Continuity From Hospital to Territory in Lombardy: TELEMACO Project

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The American Journal of Managed Care, March 2012, Volume 18, Issue 3

The TELEMACO project successfully used telemedicine to establish a healthcare continuity from hospital to territory in remote areas of the Lombardy region of Italy.

Objectives:

To verify implementation and use of TELEMACO (TELEMedicina Ai piccoli COmunilombardi; http://www.telemaco.regione.lombardia.it/), which provides specialized continuity of care with innovative healthcare services in remote areas of the Lombardy region of Italy; to design a network in the territory for sharing of continuityof- care programs; and to allow the relevant health authorities to collect cost data to establish a model for sustainable pricing for implementing these services.

Methods:

TELEMACO provides home-based telemanagement services for patients with chronic heart failure and chronic obstructive pulmonary disease (COPD), as well as second-opinion teleconsultations in cardiology, dermatology, diabetology, and pulmonology for general practitioners and second-opinion teleconsultations on digital images in cases of traumatic brain injury and stroke. A total of 2 service centers, 10 cardiology and pneumology departments, 30 specialists, 176 general practitioners, 40 nurses, 2 emergency departments, and 2 consultant hospitals were involved.

Results:

A total of 166 patients with chronic heart failure and 474 patients with COPD were enrolled. There were 4830, 51, and 44 second-opinion teleconsultations for cardiologic, dermatologic, and diabetic conditions, respectively. There were 147 second-opinion teleconsultations on digital images, 68 for stroke, and 79 for traumatic brain injury. Implementation of TELEMACO introduced innovations in working methods and provided evidence to the health authorities for allocating funds for such services.

Conclusions:

TELEMACO provided evidence that there is a growing need for home management of patients using telemedicine, a common and efficacious approach that can ensure care continuity, especially in chronic diseases.

(Am J Manag Care. 2012;18(3):e101-e108)

  • The TELEMACO project enabled structured management of patients with chronic heart failure and chronic obstructive pulmonary disease who lived in remote areas of the Lombardy region of Italy.

  • TELEMACO demonstrated the potential of telemedicine to support general practitioners in management of cardiologic conditions.

  • TELEMACO also allowed development of innovative medical and nursing skills that are becoming part of the routine medical care practice.

  • Overall evaluation of services showed that more than 95% of patients had a degree of satisfaction with the project.

Use of information and communication technology has rapidly increased worldwide and has contributed significantly to the clinical and health delivery sectors.1 Information and communication technology provides medical care to patients who have poor access to hospitals while at the same time ensuring continuity of care and optimal use of the available health resources.2-5

Telemedicine (TM) is widely implemented in rural communities, where residents face factors that can create disparities and difficulties in provisions of healthcare.6,7 The primary benefit of TM in these areas lies in facilitating remote access to healthcare and reducing cost of access, thus promoting better outcomes.8-10 Moreover, an aging population, a group in whom the incidence of chronic or degenerative diseases tends to increase, can also benefit from TM since TM can provide more efficient, prompt, and appropriate diagnostic and therapeutic services.

Our project, entitled TELEMACO (TELEMedicina Ai piccoli COmuni lombardi; http://www.telemaco.regione.lombardia.it/), is an assignment pursuant to regional Law 11/2004: “Measures to support the small municipalities of Lombardy aimed at counteracting the depopulation of the territory.” This law was developed to provide specialized continuity of care with innovative healthcare services in remote areas of the region.

The aims of the project were 3-fold: (1) to implement and use continuity-of-care services in the Lombardy region of Italy; (2) to design a network in the territory for sharing continuity-of-care programs for the management of chronic diseases; and (3) to allow the health authority of the Lombardy region to collect data to establish sustainable pricing at the regional health level for implementing TM.

MATERIAL AND METHODS

Territories with socioeconomic and infrastructural difficulties were selected within the rural areas of the Lombardy region, in conjunction with local health authorities and hospitals. Three study programs were introduced, as detailed below.

Home-Based Telemanagement for Patients With Chronic Heart Failure or Chronic Obstructive Pulmonary Disease

The methods were extensively described in previous articles.11-13 In brief, the chronic heart failure (CHF) group consisted of patients with New York Heart Association (NYHA) class II-IV left ventricular systolic dysfunction with ejection fraction less than 40% or CHF with diastolic dysfunction, with at least 1 episode of hospitalization for CHF within previous 6 months. The chronic obstructive pulmonary disease (COPD) group consisted of patients with stage III-IV COPD according to Global Initiative for Chronic Obstructive Lung Disease guidelines who received long-term oxygen therapy at home for at least 3 months, or were treated in hospital, in the outpatient setting, or in the emergency department for respiratory failure. Patients who could not be discharged from the hospital and those with severe cognitive impairment or other diseases with poor prognosis were excluded.

All patients were screened for eligibility before hospital discharge and all provided informed consent.

Before discharge from the hospital all patients were given instruction on their respective disease conditions (CHF or COPD). Patients were given pointers for recognizing signs and symptoms of decompensation/worsening. Patients with CHF were provided with a portable 1-lead electrocardiogram (ECG) device (Card-Guard 2206). Patients with COPD received a pulse oximeter (Vitalaire, Italy) device.

The home-based telemanagement (HBT) service was organized with a 6-month follow-up, with the possibility of readmission to the service for an additional 6 months. It consisted of scheduled calls done by a nurse and occasional calls done by patients. During the scheduled calls, the nurse carried out a scheduled standardized interview on the general clinical condition of the patients, including the names and the doses of prescribed drugs and patient compliance. During these calls the nurse reinforced the initial educational intervention and the strategies offered to improve the patient’s compliance. Occasional calls were made by patients in case of symptoms or signs of possible decompensation/worsening.

During either scheduled or occasional calls, CHF patients could transmit via landline or mobile phone the recording from the 1-lead ECG to a service center, and talk to the nurse or doctor 24 hours a day, 7 days a week. The COPD patients were not required to transmit any data.

Both at the beginning and at the end of the program, on an outpatient basis, a clinical evaluation together with instrumental analyses such as an echocardiogram and a 6-minute walking test in CHF patients and hemogasanalysis in COPD patients were performed. Moreover, patients were asked to complete a qualityof- life questionnaire (ie, the Minnesota Living Heart Failure Questionnaire14 and the Saint George Questionnaire15 for CHF and COPD patients, respectively). Satisfaction was assessed by a questionnaire prepared ad hoc for the project.

Second Opinion for General Practitioners in Cardiology, Dermatology, Diabetology, and Pulmonology

The method has been described in detail in a previous work.16 The service was provided to general practitioners (GPs) working in rural areas of the Lombardy region through a service center during daily in-office or home visits. For cardiac problems, GPs were equipped with a 12-lead ECG device (Card-Guard 7100, Rehovot, Israel) that could be interfaced to a landline or mobile telephone, thus transferring in real time the recorded ECG tracing back to the receiving station. 17 For dermatologic problems, the doctors used a highresolution digital camera. The GPs transmitted the images by electronic mail to the service center. Problems related to diabetology and/or pulmonology were addressed by a telephone contact only.

The service center was implemented for cardiac consultation 24 hours a day, 7 days a week. For the other specialties, the service center was implemented from Monday to Friday from 8:00 am to 8:00 pm. Cardiology, pulmonology, and diabetology teleconsultations were performed in real time, while dermatology teleconsultations were performed within 30 minutes. All conversations with health professionals were recorded.

Second Opinion on Digital Images for Traumatic Brain Injury and Stroke Between Rural Hospitals and Specialized Hospitals

Two centers, each referring to a consultant hospital, were activated. Those patients who arrived at the emergency department with signs or symptoms of suspected traumatic brain injury or stroke were enrolled.

After documenting the patient’s information and the severity scale adopted (National Institutes of Health Stroke Scale18 or Glasgow Coma Scale19) in the patient’s health record, the emergency department physician sent the images (computed tomography) to the specialists at the reference hospital (neuroradiologist, neurologist, or neurosurgeon) and asked for a teleconsultation. The consulting physician had access to the images and data, and could give his/her diagnostic and therapeutic indications. Expert opinion was available within 30 minutes of arrival of images.

The 2 service centers offered technological support for transmitting the relevant medical data and management of clinical data that were collected. Service centers offered telephone clinical support overnight and during holidays, managed by professional staff (expert nurses and specialists) connected via telework.20 In addition, service centers provided training courses to all professionals involved.

During the study, field training programs (clinical audit/training activities) were organized. Training of health professionals included face-to-face classes and audioconferences to provide theoretical and practical knowledge on the basics of TM, associated technologies, sending data and tracings, and filling in the personal health record of the patient. An overview of the application models was also provided, together with information on the overall organization of the system and service model, types of requests, and responses to the teleconsultation. In addition, education on the care of patients with cardiac or respiratory diseases was provided.21

Efficacy Measures

The outcome measures for the 3 project programs were the following:

1. Assessment of the extent of TELEMACO services. This issue was addressed by evaluating the number of patients enrolled in the HBT program. The diffusion of HBT services for CHF and COPD patients was assessed in a single area of the Lombardy region (Valle Camonica). For CHF, the number of patients enrolled in the HBT program was compared with the number of patients enrolled in the HBT in Valle Camonica. For evaluating the diffusion of HBT, the total number of patients hospitalized in Valle Camonica represented the total population that could potentially access the HBT service. For COPD, the prevalence of disease in the territory (3% of the population has COPD, calculated as shown at www.goldcopd.it) was compared with the percentage of the patients enrolled in the HBT program.

2. A ssessment of TELEMACO network. This assessment was done by evaluating the organization of the integrated services across the Lombardy territories.

3. Acceptance of TELEMACO services by the regional authorities. This assessment was done by determining whether a system of reimbursement for the services provided could be implemented by the regional authorities after the project was completed.

Statistical Analysis

Data are expressed as numbers, percentages, or means ± SD. A Wilcoxon test for paired data was used to assess significance of the improvement of clinical parameters.

RESULTS

Assessment of the Extent of TELEMACO Services

Figure 1

shows the areas involved in the project of the Lombardy region and indicates for each area the number of patients and relevant teleconsultations.

Home-Based Telemanagement for Patients With CHF or COPD

A total of 10 cardiology and 7 pulmonology departments that carried out HBT for CHF and COPD patients were involved.

Table 1

A total of 166 patients with CHF were included (mean age 69 ± 13 years, 70% male), 62% of whom were diagnosed with CHF 6 months before TELEMACO, with the remaining 38% in the preceding 6 to 48 months. At enrollment, 13%, 82%, and 5% of patients were in NYHA class II, III, and IV, respectively; 58% of patients had at least 1 comorbidity, in particular diabetes, COPD, and chronic renal insufficiency. During the HBT intervention (193 ± 53 days), the planned telephone contacts averaged 1.2 per patient per week. During the program, there were 46 hospitalizations, 50% of which were for cardiovascular reasons. At the end of the 6-month program, improvement of the clinical conditions of the patients was observed: they actually were more stable when discharged from the program ().

A total of 474 patients with COPD (mean age 72 ± 8 years, 76% male) were included: 72% ex-smokers, 16% current smokers, 26% obese, and 36% overweight. During the HBT intervention (179 ± 45 days), the planned telephone contacts averaged 1.1 per patient per week. During the program, there were 83 hospitalizations, 47% of which were for pulmonology reasons.

Table 2

There were no significant differences in clinical parameters measured at the beginning and end of the program, thus indicating that the patients’ condition was relatively stable. The St. George quality-of-life questionnaire (divided into 3 areas of analysis: Symptoms, Activity, and Impact) shows a marked improvement in patients’ perceived quality of life (high values on the Saint George questionnaire correspond to lower quality). These improvements are statistically significant and are particularly pronounced in the Activity section ().

Of a total population of about 10 million people (www.istat.it) in the Lombardy region, 25,403 (0.26%) patients were hospitalized for CHF in 2007. This rate was similar to that reported for Valle Camonica, with a total population of about 98,224 and 274 (0.28%) patients hospitalized for CHF during the same year. Thus, the percentage of HBT diffusion for CHF in this area was 23.7%.

There were 2947 COPD patients in the Lombardy region, which represents a prevalence of 3%. By considering only the Local Health Authorities of Valle Camonica (the district in which data can be considered representative since it is the only district of the area), the HBT service diffusion was 1.43%.

Second Opinion for GPs in Cardiology, Dermatology, Diabetology, and Pulmonology

There were 176 GPs working in 7 areas of the Lombardy region involved in this project. They required 4830 cardiologic teleconsultations (mean duration was 6.1 ± 3.5 min) following the reporting of as many ECGs, 51 dermatology teleconsultations (mean duration was 9.4 ± 4.9 min), and 44 diabetic teleconsultations (10.8 ± 5.8 min). The mean age of patients for whom GPs had requested a cardiology, dermatology, or diabetic teleconsultation was 62 ± 20 years, 47 ± 26 years, and 73 ± 12 years, respectively. The reasons for contacts in cardiologic, dermatologic, and diabetology teleconsultations were planned checks in 58%, 14%, and 61%, respectively; symptoms in 39%, 43%, and 12%, respectively; and others in 3%, 43%, and 27%, respectively. No consultation was used for pulmonology.

Second Opinion on Digital Images for Traumatic Brain Injury and Stroke Between Rural Hospitals and Specialized Hospitals

The 2 hospitals involved requested 147 teleconsultations, 68 teleconsultations for stroke, and 79 teleconsultations for traumatic brain injury. For 18% of patients, the consultant specialist suggested hospitalization. For the other patients, the specialist suggested an observation period with therapy (31%), further examinations (18%), or discharge after treatment (9%).

Assessment of TELEMACO Network

Figure 2

shows the network set up during the TELEMACO project. Implementation of TELEMACO resulted in introduction and sharing of innovations in procedures and working methods. TELEMACO has also created consensus on clinical pathways, facilitating the subsequent recognition of the regional value of the project.

During TELEMACO, training was provided to 40 nurses from departments of cardiology, pulmonology, and internal medicine. They received instructions on prearranged topics and guided use of computerized clinical records (1) through face-to-face meetings for a total of 174 hours and (2) through audioconference during which information was shared with the clinical nurse teacher for a total of 225 hours.

The training also provided playback of 20 calls per each trained operator and rereading of 20 ECGs. More than 180 GPs needed face-to-face training sessions

of at least 3 to 4 hours. All requests for teleconsultation were considered “training in the field.” For each of the 30 specialists, the playback of at least 20 calls and rereading of 20 ECGs (cardiology only) were carried out annually. Both the traditional training and the training courses in the field have been accredited under the system of credit regional recognition.

Acceptance of TELEMACO Services by the Health Authority

Table 3

In order to guarantee continuity of care with TELEMACO, the health authority of the Lombardy region decided to implement new health networks that could guarantee home care to patients with chronic or postacute diseases. Implementation of the service with anticipated costs was authorized by Lombardy Ministry Decree # IX/409 of August 5, 2010 (). The regional health system fixed the cost per patient per 6 months for CHF and COPD HBT at €720.00. This sum included several expenses (those for service center operations, rental for 1-lead ECG or pulse oximetry, reimbursement for specialists’ second opinions, and the nurse-tutor’s costs [de visu activity, bureaucracy, and telephone calls]). Specialists’ cost activity is also included in the above sum. The second-opinion teleconsultation, which included 12-lead ECG, cost an average of €18.00.

DISCUSSION

The TELEMACO project was organized with the aim of combining management, clinical, and technological tools to improve provision of healthcare in rural areas, from secondary care community hospital settings to home care.22 To this end, TELEMACO was able to activate in rural areas a structured management program for patients with CHF and COPD, allowing integration between hospital and territory. Scientific studies and subsequent meta-analysis show how these new models have a positive impact on the patient management.2-4 More that 95% of patients expressed their overall satisfaction with the service as well as with the ease of use of the equipment through an ad hoc questionnaire. The relationship with the nurse-tutor was positive for 98% of patients.

The TELEMACO project demonstrated the potential of telemedicine to support GPs, even if limited to cardiologic conditions. We observed that GPs were motivated to use the service. These data seem to support the data reported in the literature: with the developments in technology and the decrease in costs, telecardiology seems to have considerable potential to bridge the gap between primary and secondary care.23

Second-opinion teleconsultation about digital images has shown encouraging results. TELEMACO provides preliminary indications that the service can ensure more appropriate decisions in the diagnostic phase, thus possibly avoiding unnecessary transfers.

TELEMACO also allowed development of innovative medical and nursing skills that are now becoming part of routine medical care in dedicated hospital units. In fact, implementation of TM in the healthcare system requires the need for new roles and responsibilities for the nurses.24

Through the activities of the project (study design, training, communication, technology integration, assessment, management), we created a network that contributed to the overall success of the program.

The involvement of companies operating in small municipalities, often in mountainous areas, depended greatly on the ability to understand the clinical and organizational needs of the areas involved. However, this also stimulated the design of flexible solutions and encouraged commitment to the project.

Telemedicine has contributed to the overall result in 4 ways: (1) introduction and sharing of innovations in procedures and working methods among all operators, (2) professional growth of the operators themselves, (3) entrusting change management to an external entity with appropriate skills and expertise, and (4) a broader spectrum of support, besides technology, that created a network to support healthcare professionals.

The TELEMACO project found that TM can also be used to improve the chain of care and may involve a complex delivery system that uses a mixture of technologies. This was one of the most important results of the study. In particular, the services offered in TELEMACO are consistent with the new deal proposed by the Ministry of Health, in particular regarding the need for profound technological innovation not only in clinical and diagnostic areas but also in the culture and politics of evaluation, which is the significant innovation to be introduced in the health system to be on the side of citizens and become part of the real right of health protection. At the Italian National Health System level, telemedicine is used only in a few regions and settings, thus needing to be spread all over the territory. This could be accomplished if culture and politics of evaluation recognize its importance. We believe that TELEMACO provided some incentive to this end.

This study has a limitation in that it was not randomized; the decision to join or not join the service was up to the patient (and doctor) in the case of remote locations and up to the GP in the case of the second opinion. There are now numerous meta-analyses demonstrating the effectiveness of the multidisciplinary model in chronic diseases.2-4 Therefore, the main interest in the Lombardy region was not to demonstrate the effectiveness of existing evidence-based models,11,12 but rather to start up a multidisciplinary model in areas where the patient was sent home and supported only by the GP. The purpose was to extend as much as possible the management model at the regional level, involving a number of different health professionals with new skills and allowing their interaction in a more efficient network.

Many hospitals and health systems are focusing on improving the management of chronic diseases to prevent readmissions, decrease costs, improve patient satisfaction, and improve the quality of results and quality of life. All these factors will become increasingly important in the choice made by patients of the medical staff and health system services. It is crucial that changes occur in the organizational capacity of health structures.25

CONCLUSIONS

TELEMACO has provided preliminary evidence that there is a growing need for home management of patients with common conditions and for more efficacious protocols to ensure continuity of care, especially in chronic disease settings. However, several issues and technical aspects must still be taken into consideration to expand this kind of novel approach. The percentages of service diffusion found in the current study (23.7% and 1.43% in CHF and COPD patients, respectively) indicate that much remains to be done to increase the diffusion of the TM approach. The Lombardy region has been capable of and quite experienced in implementation of the innovative pathways proposed by TELEMACO and has decided to allocate these innovative pathways of healthcare at the regional level.Acknowledgments

We thank all the participants in the TELEMACO project:

Italian Ministry of Health: M. Casciello, R. Ugenti, L. Di Minco.

Lombardy region—D.G. Sanità: C. Lucchina, L. Merlino, C. Penello, E. Bosio, M. Trovato, C. Carrozza, R. Veneri, R. Gorio, A Colnaghi.

Health Telematic Network: M. Nardi, G. Martinelli, D. Zeminian; Cefriel: A. Castelli, C. Colombo, A. Radice, D. Peroni, A. Garlaschelli; Telbios: A. Baro, R. Beretta, A. Mason; ItalTBS: M. Parrella, V. Ventimiglia; Telecom: L. Zampetti, L. Speranza.

Politecnico di Milano: L. Bartoli, A. Raimondo, S. Rusconi.

ASL Bergamo: L. Berti, G. Imbalzano, L. Perego, V. Brancato, G. Barcella, B. Baronchelli, E. Bernini, E. Cressoni, M. Filisetti, F. Fiorina, R. Fiorina, S. Novelli, G. Pacchiani, R. Sala, M.D. Valvassori, F. Zamboni. Ospedali Riuniti Hospital: N. Cuocina. Bolognini Hospital: V. Giudici, M. Tespili, M. Tumiati, G. Giudici, A. Alborghetti. Locatelli Hospital: P. Maietta, A. Comelli, L.V. Pasinetti, M.R. Perani.

ASL Brescia: F. Lonati, F. Vassallo, F. Besozzi Valentini, F. Caloria, A. Tirinato, E. Begliutti, R. Belleri, G. Beltrami, C. Cucchi, G. Damiata, A. Donatini, M. Pelizzari, G. Procopio, A.D. Rimedio, R. Rizzini, S. Shahrokh, D.G. Zani. Spedali Civili Hospital: B. Agosti, E. Zarra. Gardone Valtrompia Hospital: N. Pagnoni, G. Siena, I. Poli, E. Melzani, B. Ragona, S. Serbu, C. Betti. Mellini Hospital: A. Indelicato, C. Gentilini, M. Ferliga, D. Sereni, A. Pontoglio, F. Guastini, E. Pasinetti, L. Barbieri, E. Bariselli, F. Dalla Valle, D. Domeneghini. Poliambulanza: A. Signorini, A. Maggi, E. Donati, P. Invernizzi, R. Poeta. Manerbio Hospital: M. Benigno, C. Ferretti, C. Zappa. Fondazione Salvatore Maugeri: A. Giordano, J.P. Ramponi, D. Baratti, G. Assoni, E. Mandora, M. Vitacca, S. Gilè, L. Barbano, L. Bianchi, L. Bertella, D. Fiorenza, R. Porta, A. Cinelli.

ASL Como: G. Iafolla, S. Barba, M. Burzio, N. Capone, A. Giossi, S. Guanella, A. Guffanti, L. Palo, E. Pasotti, C. Pizzagalli, A Robbiati, F. Rossini, P.M. Strada, W. Sgroni, G. Zavatarelli.

ASL Lecco: R. Moretti, V. Valsecchi, G. Arrigoni, G. Bellini, M. Maroni, A. Menga, V. Pisani, D. Sferco, L. Tamagnini. Manzoni Hospital: P.F. Ravizza, B. Casiraghi, A. Crotta.

ASL Pavia: V. Moro, T. Repossi, G. Alessi, G. Ammirati, L.A. Bosco, P.L. Burroni, M.G. Calzavara, M. Campagnoli, M. Catone, F. Chiesa, C. Cignatta, G. Giuffré, P. Longo, M. Menini, G. Mussini, E. Orlandi, M. Pecorini, P. Rebasti, M. Tascome, L. Valle. Provincia di Pavia Hospital: E. Coperchini, M. Marinoni, P. Mazzocchi, L. Bellodi, F. Fiorenza, L. Corolli, F. Chiofalo, C. Vaccari, C. Moccia.

ASL Sondrio: G. Bellagamba. Valtellina e Valchiavenna Hospital: G. Besozzi, M.A. Papalia, L. Iannacci, N. Partesana, P. Giumelli, V. Robustelli Test, N. Aili.

ASL Varese: M.G. Buzzi, E. Marmondi, A. Arioli, E.E. Colombo, G. Costantini, P. D’Agostino, M. D’Anna, E. De Giacomo, M. Frusteri, G. Lia, R. Nardi, T. Pedroni, L. Pezzoni, G. Pirrotta, M. Pizzi, F. Rapetti. Macchi Hospital: W. Bergamaschi, R. Riva, M. Zorzan, M.L. De Lodovici, F. Perlasca, A. Salzillo, F. Colombo, F. Semeraro, M. Rossin, G. Rocco, T. Quinto, C. Tuccio, M. Conti, S. Pastone, O. Corti, L. Astone, G. Donnarumma, C. Metrotta, G. Radosti, A. Tozzi, M. Caprani, R. Rotteri, M. Genzi, R. Campagnani, F. Compagnoni, S. Greco, A. Spanu.

ASL Valle Camonica Sebino: R. Coccaglio, A. Albertinelli, G. Bandera, A. Bazzana, F. Belafatti, P. Bellicini, P. Binda, A. Brescia, A. Camoni, E. Camossi, S. Capello, A.L. Castagna, S. De Giacomi, D. De Santis, G. Do, V. Do, A. Gheza, M. Gheza, R. Gheza, R.M. Giarelli, G. Manella, I. Maranta, P. Massussi, G. Mastroeni, S. Mometti, P. Pasqua, S. Poiatti, G. Sabbadini, S. Simoncini, G. Tampini, E. Tignonsini, R. Totis, A. Visinoni, F. Romellini. Esine Hospital: L. Salada, P. Pellegrini, N. Bretoni, M. Soccio, P. Conti, S. Sigorini, A. Bernardi.

Guastalla Hospital, Reggio Emilia: P. Vasini. Busto Arsizio Hospital: E. Cazzani. Crema Hospital: A. Lodi Rizzini, P. Gazzaniga. ASL Genova: G. Tommasini. Università Tor Vergata, Roma: A. Di Stefani, A. Giunta. Hospital San Camillo (Roma): M. Pugliese.

We are also indebted to Dr Alessandro Bettini for editing the manuscript.

Author Affiliations: From Fondazione Salvatore Maugeri (PB, SS), IRCCS, Telemedicine Service, Center of Lumezzane, Lumezzane (Brescia), Italy; Health Directorate (CT), San Carlo Borromeo Hospital, Milan, Italy; CEFRIEL (GBB), Milan, Italy; Department of Management, Economics and Industrial Engineering (PZ, CME), Politecnico di Milano, Milan, Italy; Health Telematic Network (FG), Brescia, Italy; Cardiology Department (MM), San Carlo Borromeo Hospital, Milan, Italy.

Funding Source: Ministry of Health, Ministry of Innovation and Technologies and Lombardy region: regional Law 11/2004; DGR No VII/19768 of 10/12/2004 and INTESA ISTITUZIONALE di PROGRAMMA tra il Governo della Repubblica Italiana e la regione Lombardia - II Atto integrativo dell accordo di programma Quadro in Materia di Società dell Informazione nella regione Lombardia. Funding received for the TELEMACO Project is summarized as follows: Funding from Ministry of Health: €1,600,000.00. Funding from Ministry of Innovation and Technologies: €450,000.00. Funding from Lombardy region €1,386,084.86. Total: €3,436,084.86.

Author Disclosures: The authors (PB, SS, CT, GB, PZ, CM, FG, MM) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. Authorship Information: Concept and design (SS, CT, GB, CM, FG, MM); analysis and interpretation of data (PZ, CM); drafting of the manuscript (PB, SS); critical revision of the manuscript for important intellectual content (PB, SS, GB, PZ, CM, FG, MM); statistical analysis (PZ); provision of study materials or patients (FG); obtaining funding (CT); administrative, technical, or logistic support (PB, CT, GB); and supervision (PB, SS, CT, GB, CM, FG, MM).

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