**7. New key aspects of COPD management at home: Telemonitoring and teleradiology**

The challenges that are posed to the health care sector in terms of using innovative tools and methods are relevant. Issues like the growing of ageing population and of citizens in chronic conditions are the focus of the last medical progress, which offer new and better treatments.

Telecare and telemedicine are promising if considered as solutions for different particular conditions, such as rural regions and all the situations where the healthcare services could cope with a shortage of specialists or equipments.

Telemedicine, moreover, connecting hospital and homes could - in some cases - contribute to avoiding the traditional hospital admission, resulting less stressful for patients, and money saving as well. Technology can also improve the quality of life by supporting informal carers, making it more likely that people receiving care and their informal carers can continue to stay active at home and in the community instead of being institutionalized. With developments in medical and other technologies, people with very complex conditions may increasingly be treated at home rather than in hospital or institutional care. In San Diego, California, physicians arrive at patients' homes with a new version of the black bag that includes a mobile x-ray machine and a device that can perform more than 20 laboratory tests at the point of care. Landers recent opinion is that "the venue of care for the future is the patient's home, where clinicians can combine old-fashioned sensibilities and caring with the application of new technologies to respond to major demographic, epidemiologic, and health care trends. Five major forces are driving health care into the home: the aging population, epidemics of chronic diseases, technological advances, health care consumerism, and rapidly escalating health care costs" (Landers, 2010).

Telemonitoring devices have been tested on an elderly HHS population in Torino. In November 2008 Telecom Italia (TI), "San Giovanni Battista" Hospital and "Mario Boella" Institute (ISMB) of Torino started a project called *MyDoctor@Home*, for telemonitoring patients affected by an acute exacerbation of COPD or acute heart failure, managed at home by the HHS of "San Giovanni Battista" Hospital.

MyDoctor@Home (Figure 3) is an e-health service that enables the patient to measure at home, with portable and Bluetooth connected medical devices, his own physiological parameters and to transmit them in real time, through a mobile phone, to a platform operating in a TI data center, accessed by the sanitary structure. The patients use the mobile phone in order to transmit the measures, and they may also receive messages reminding them to take measurements and/or to follow their medication schedule.

Through the web platform "MyDoctor@Home", physicians or nurses can monitor in real time or from remote the received measures and can interact with the patient in different modalities (telephone, video-calling, visit at home) (Figure 4).

of 25 + 8.7 days. Only HHS patients experienced improvements in depression and quality of life scores. Satisfaction at discharge was very good or excellent for 94% of HHS patients and 88% of acute hospital patients (p=0.83). On a cost per patient per day basis, HHS costs were lower than costs in GMW (\$ 101.4 ± 61.3 versus \$ 151.7 ± 96.4, p=0.002). Analysis of costs for hospital-at-home patients revealed that 79% of costs were due to drugs, durable medical

equipment, diagnostic procedures, medications, and other nonstaff costs.

cope with a shortage of specialists or equipments.

and rapidly escalating health care costs" (Landers, 2010).

by the HHS of "San Giovanni Battista" Hospital.

**teleradiology** 

**7. New key aspects of COPD management at home: Telemonitoring and** 

The challenges that are posed to the health care sector in terms of using innovative tools and methods are relevant. Issues like the growing of ageing population and of citizens in chronic conditions are the focus of the last medical progress, which offer new and better treatments. Telecare and telemedicine are promising if considered as solutions for different particular conditions, such as rural regions and all the situations where the healthcare services could

Telemedicine, moreover, connecting hospital and homes could - in some cases - contribute to avoiding the traditional hospital admission, resulting less stressful for patients, and money saving as well. Technology can also improve the quality of life by supporting informal carers, making it more likely that people receiving care and their informal carers can continue to stay active at home and in the community instead of being institutionalized. With developments in medical and other technologies, people with very complex conditions may increasingly be treated at home rather than in hospital or institutional care. In San Diego, California, physicians arrive at patients' homes with a new version of the black bag that includes a mobile x-ray machine and a device that can perform more than 20 laboratory tests at the point of care. Landers recent opinion is that "the venue of care for the future is the patient's home, where clinicians can combine old-fashioned sensibilities and caring with the application of new technologies to respond to major demographic, epidemiologic, and health care trends. Five major forces are driving health care into the home: the aging population, epidemics of chronic diseases, technological advances, health care consumerism,

Telemonitoring devices have been tested on an elderly HHS population in Torino. In November 2008 Telecom Italia (TI), "San Giovanni Battista" Hospital and "Mario Boella" Institute (ISMB) of Torino started a project called *MyDoctor@Home*, for telemonitoring patients affected by an acute exacerbation of COPD or acute heart failure, managed at home

MyDoctor@Home (Figure 3) is an e-health service that enables the patient to measure at home, with portable and Bluetooth connected medical devices, his own physiological parameters and to transmit them in real time, through a mobile phone, to a platform operating in a TI data center, accessed by the sanitary structure. The patients use the mobile phone in order to transmit the measures, and they may also receive messages reminding

Through the web platform "MyDoctor@Home", physicians or nurses can monitor in real time or from remote the received measures and can interact with the patient in different

them to take measurements and/or to follow their medication schedule.

modalities (telephone, video-calling, visit at home) (Figure 4).

Fig. 3. The MyDoctor@Home Platform

Fig. 4. MyDoctor@Home: Computer work station at HHS office

Hospital at Home for Elderly Patients

home

with Acute Exacerbation of Chronic Obstructive Pulmonary Disease 391

Fig. 5. Mobile tele-radiology station: equipment and Radiology Technicians at patient's

Fig. 6. Mobile tele-radiology station: computed radiography system

The system enables the physician to the definition of value thresholds that can be personalized on the basis of single clinical situations. The platform informs the physician on recent measures by sending an SMS so that he can activate quickly the appropriate actions. There is a reduction of reaction times also when the nurse, during the visit at home, sends to the doctor measures performed with professional devices, like for example the ECG or the spyrometer, receiving, quickly, the feedback of the exams and instructions such as for example the variation of the therapy.

Eighteen patients have been involved in the study between June 2009 and June 2010 (27% with a COPD exacerbation), with a mean age of 86 years. All patients were functionally and cognitively impaired, with a poor quality of life. Instruments for telemonitoring resulted easy to use. The use of the equipment of telemonitoring had the benefit to avoid 24 visits by nurses and doctors on the sample in exam. Of them, 15 were substitued by phone contacts on therapy adjustments due to clinical parameter alterations registered by telemonitoring and 9 were substitued by phone counselling. Our preliminary data suggest that the use of our devises could have a reassuring role on the caregivers. Moreover, it has been demonstrated a significantly progressive reduction in the stress levels of caregivers from the baseline to the discharge (Aimonino Ricauda et al., 2011). Nevertheless, the sample size was small and the findings may not be generalizable, given that the study was conducted at only one centre and by an operationally mature hospital-at-home unit. There is the need for better quality studies in the future that can establish a clear role for telemonitoring as an adjunct to intermediate care.

Transporting radiology to the patient's home is challenging. Preliminary experiences indicate that the coupling of simple, light-weight X-ray equipment with an advanced CRdetector system proves effective for externalization of radiographic service. The image and examination quality has been proved to be the same or insignificantly lower than those performed with a stationary equipment and analysis on safety of radio-protection systems show a very low risk exposure for health staff as well as for the general population.

The study of Laerum and collegues showed that mobile, digital radiography service prove better for the nursing home patients at a compatible examination and imagine quality, and a substantially reduced cost for society (Laerum et al., 2005). The study of Sawyer concluded that domiciliary radiography services could be suitable for selected groups of patients (Sawyer et al., 1995).

A pilot study on domiciliary teleradiology service has been conducted at the HHS of Torino between June 2008 and June 2009. Acutely ill HHS patients in need of a radiological examination were randomly assigned to perform imaging at home (Intervention group, n=34) or in hospital (Control group, n=35). Inclusion criteria were: immobilization or chairbound, need for chest, pelvis/hips, joints, upper and lower limbs, hands and feet, abdomen X-rays, absence of definite delirium at enrollment according to the Confusion Assessment Method (CAM) (Inouye et al., 1990) and presence of intermediate or high risk of delirium according to the criteria of Inouye (Inouye et al., 1993), . The radiological examinations were performed at home by two qualified Radiology Technicians (RT) using a portable high frequency X-ray tube, improved cassettes (with imaging plate inside) and a mobile radiological station (Computed Radiography POC 260, Carestream) with visualization and real-time processing of acquired images (Figure 5, Figure 6). Using the Picture Archive and Communication System (PACS) of our hospital acquired images were

The system enables the physician to the definition of value thresholds that can be personalized on the basis of single clinical situations. The platform informs the physician on recent measures by sending an SMS so that he can activate quickly the appropriate actions. There is a reduction of reaction times also when the nurse, during the visit at home, sends to the doctor measures performed with professional devices, like for example the ECG or the spyrometer, receiving, quickly, the feedback of the exams and instructions such as for

Eighteen patients have been involved in the study between June 2009 and June 2010 (27% with a COPD exacerbation), with a mean age of 86 years. All patients were functionally and cognitively impaired, with a poor quality of life. Instruments for telemonitoring resulted easy to use. The use of the equipment of telemonitoring had the benefit to avoid 24 visits by nurses and doctors on the sample in exam. Of them, 15 were substitued by phone contacts on therapy adjustments due to clinical parameter alterations registered by telemonitoring and 9 were substitued by phone counselling. Our preliminary data suggest that the use of our devises could have a reassuring role on the caregivers. Moreover, it has been demonstrated a significantly progressive reduction in the stress levels of caregivers from the baseline to the discharge (Aimonino Ricauda et al., 2011). Nevertheless, the sample size was small and the findings may not be generalizable, given that the study was conducted at only one centre and by an operationally mature hospital-at-home unit. There is the need for better quality studies in the future that can establish a clear role for telemonitoring as an

Transporting radiology to the patient's home is challenging. Preliminary experiences indicate that the coupling of simple, light-weight X-ray equipment with an advanced CRdetector system proves effective for externalization of radiographic service. The image and examination quality has been proved to be the same or insignificantly lower than those performed with a stationary equipment and analysis on safety of radio-protection systems

The study of Laerum and collegues showed that mobile, digital radiography service prove better for the nursing home patients at a compatible examination and imagine quality, and a substantially reduced cost for society (Laerum et al., 2005). The study of Sawyer concluded that domiciliary radiography services could be suitable for selected groups of patients

A pilot study on domiciliary teleradiology service has been conducted at the HHS of Torino between June 2008 and June 2009. Acutely ill HHS patients in need of a radiological examination were randomly assigned to perform imaging at home (Intervention group, n=34) or in hospital (Control group, n=35). Inclusion criteria were: immobilization or chairbound, need for chest, pelvis/hips, joints, upper and lower limbs, hands and feet, abdomen X-rays, absence of definite delirium at enrollment according to the Confusion Assessment Method (CAM) (Inouye et al., 1990) and presence of intermediate or high risk of delirium according to the criteria of Inouye (Inouye et al., 1993), . The radiological examinations were performed at home by two qualified Radiology Technicians (RT) using a portable high frequency X-ray tube, improved cassettes (with imaging plate inside) and a mobile radiological station (Computed Radiography POC 260, Carestream) with visualization and real-time processing of acquired images (Figure 5, Figure 6). Using the Picture Archive and Communication System (PACS) of our hospital acquired images were

show a very low risk exposure for health staff as well as for the general population.

example the variation of the therapy.

adjunct to intermediate care.

(Sawyer et al., 1995).

Fig. 5. Mobile tele-radiology station: equipment and Radiology Technicians at patient's home

Fig. 6. Mobile tele-radiology station: computed radiography system

Hospital at Home for Elderly Patients

with Acute Exacerbation of Chronic Obstructive Pulmonary Disease 393

The importance of targeting appropriate interventions to appropriate patients has been seen in studies of home care services in which more intensive interventions that included

Despite the evidence supporting hospital-at-home care, it has had relatively limited dissemination worldwide. Hospital-at-home care is a complex clinical model and, as such,

Our experience suggests that a mature, physician-led, substitutive clinical unit model of hospital-at-home for elderly patients with acute exacerbation of COPD is feasible and is

To date, the evidence base is focused nearly exclusively on patient-related outcomes, rather than on outcomes of interest to potential adopter organizations. There is a need for further studies that include a larger number of patients and an economic evaluation of direct and indirect costs. Moreover, the costs of implementation and the adoption process required

Hospital at Home of Torino is a part of a comprehensive *continuum of services* at one end of which lies the hospital system and at the other end of which lie community services. Our model is well delineated from an organizational and administrative point of view, and may

Aimonino Ricauda N., Bo M., Molaschi M., Massaia M., Salerno D., Amati D., Tibaldi V. &

stroke in elderly patients: a randomized trial*. J Am Geriatr Soc* , 52, 278-283. Aimonino Ricauda N., Isaia G., Rocco M., Tibaldi V., Bergonzini M., Fiorano T., Marinello

Aimonino Ricauda N., Isaia G., Tibaldi V., Bestente G., Frisiello A., Sciarappa A., Cavallo S.,

Aimonino Ricauda N., Tibaldi V., Barale S., Bardelli B., Pilon S., Marchetto C., Zanocchi M.

Aimonino Ricauda N., Tibaldi V., Leff B, Scarafiotti C., Marinello R., Zanocchi M & Molaschi

Aimonino Ricauda N., Tibaldi V., Marinello R.*,* Bo M., Isaia G., Scarafiotti C. & Molaschi M.

randomized, controlled trial. *J Am Geriatr Soc*, 56, 493-500.

minimization analysis. *J Am Geriatr Soc,* 53, 1442-1443.

Fabris F. (2004). Home hospitalization service for acute uncomplicated first ischemic

R., Bertone P. & Isaia G.C. (2011). Il telemonitoraggio in pazienti affetti da BPCO e scompenso cardiaco acuto ospedalizzato a domicilio. *G Gerontol*, 59, 163-166.

Ghezzi M. & Larini G. (2010). Telecare and Telemedicine in home care practice: field trial results, In: *Distributed Diagnosis and Home Healthcare*, Rajendra Acharya U,

& Molaschi M. (2007). Depressive symptoms and quality of life in elderly patients with exacerbation of chronic obstructive pulmonary disease or cardiac heart failure: prelimunary data of a randomized controlled trial. *Arch Gerontol Geriatr*, Suppl. 1,

M. (2008). Substitutive "Hospital at Home" versus inpatient care for elderly patients with exacerbations of chronic obstructive pulmonary disease: a prospective

(2005). Acute ischemic stroke in elderly patients treated in hospital at home: a cost

multidimensional assessment were associated with positive outcomes.

associated with reduction in hospital readmissions and better quality of life.

faces substantial dissemination barriers (Leff, 2009).

within an health organization are to be well delineated.

be considered an example for dissemination.

American Scientific Publishers.

**9. References** 

(Italian)

7-12.

transmitted directly via wireless broadband Internet to the radiologists in the hospital who were able to read a radiograph in real time. A firewall hardware has been used in order to protect the confidentiality of patient data. Only one radiography was performed at home in all patients, mainly a chest X-ray. All patients were very old (mean age 78 years in the entire sample), mostly multimorbid, functionally and cognitively impaired, at high risk of developing delirium in 62%. After radiological examinations an acute confusional status, according to the CAM criteria, requiring pharmacological treatment (antipsychotic drugs) appeared in 17% of patients in the Control group, whereas no one in the Intervention group developed delirium. Customer satisfaction for domiciliary X-rays was very good/excellent for 94%. This study demonstrates that a mobile, digital radiography service could be a good option for frail, vulnerable elderly and immobile patients at a compatible examination and image quality, and, due to our analysis, at a substantially reduced cost for the health care system (data in press in Arch Int J, August 2011).
