1. Simonetta Scalvini, MD Head of Telemedicine Unit IRCCS Salvatore Maugeri Foundation Lumezzane (BS) - Italy OPEN DAYS - Bruxelles, 9th October 2008 Realized Benefits from Regional Telemedicine Services

2. Who we are Salvatore Maugeri Foundation (FSM; www.fsm.it ) is an IRCCS (Institute for Research and Care) in the field of Rehabilitation; FSM was born in 1965 in Pavia and after that 18 centers were born spread all over Italy. In Lombardy Region there are the most number of hospitals. www.fsm.it The activity of the Telemedicine Department in FSM started on 1998 with Health Telematic Network (HTN) to monitor chronic heart diseases; in the next years we succeeded in building services in the field of Home Telenursing, Teleconsulting between GPs and Specialists and Service Center for hospitals.

3. Who we are Health Telematic Network (HTN, S.r.l) is a Telemedicine Services Centre started as an Ltd. Company in December 1998 becoming a joint-stock Company in May 2001 with the entry of the investment capital The Service utilizes the scientific-organizational competences of Salvatore Maugeri Foundation and the technological-operative competences of HTN that supplies telemedicine services to medical structures, general practitioners, specialists and patients for 24/24 hours 365 days The Service Centre is characterized by: an advanced technological web-based platform, continuously upgraded operations 24/24 hours all year round a high skilled team an intensive use of telework a network of Hospitals, Universities, General Practitioners, Specialists and Nurses able to offer effective and efficient telemedicine services on a solid scientific basis by teleconsultation second opinion, triage and telematic instrumental services report (on line, store and forward)

5. NURSE TUTOR GP Cardiology Pneumology Radiology Psycology Rheumatology Diabetology Neurology Geriatry Psycologist Nutritionist TrainingVentilation therapy Therapy xxxxxxx

6. 1-Telecardiology community: a new approach to take care of cardiac patients. Cardiologia 1999; 44 (10): 921-24 2- Appropriatezza dellinvio in Pronto Soccorso mediante un servizio di telecardiologia sul territorio. Italian Heart Journal Suppl 2000; 1 (7): 905-909. 3- Potenziale riduzione dei costi per il Servizio Sanitario Nazionale mediante un servizio di telecardiologia dedicato ai medici di medicina generale. Italian Heart Journal 2001; 2 (10): 1091-1097 4- Chest pain prehospital assessment with a telecardiology service. Journal of Telemedicine and Telecare 2002; 8: 231-236 5- Incidence of Atrial Fibrillation in an Italian population followed by their GPs through a telecardiology service. International Journal of Cardiology 2005; 98: 215-220

7. A Giordano et al. IJC 2008, in press 230 CHF patients followed for 365 days using telephonic follow-up and ECG monitoring 230 patients in the control group. average age 57±10 y; FE 27±6 %; VO 2 13.3 ml/kg/min In the Telemedicine Group we observed a reduction in: - hospitalizations (around 44%) - destabilizations (around 50%) - costs (around 24%) Multicenter randomised trial on home based telemanagement to prevent hospital readmission of patients with chronic heart failure

8. Randomised trial on Telemedicine to save health care requests for patients with severe chronic respiratory failure M Vitacca et al., European Respiratory Journal 2008, in press Hospitalization Mortality [TM (18%) vs control (23%)] and Number of ER admissions were not statistically different groups. TM vs control group showed reduction in: o hospitalisations (-36%, p<0.02) o GP urgent calls (-65%, p<0.002) o home relapses (-71%, p<0.0001) with a higher probability to be free from first: hospitalisation (p<0.015), ER admission (p<0.002), GP urgent call (p< 0.015), home relapse (p<0.015) Calls from patient to TM staff: 36 25 times Reasons: clinical instability or therapy modification. Resolution: 63% by nurses alone. Patient and caregivers satisfaction: very high in > 92%. Average overall direct cost per each TM: reduction of 33% with respect to usual care. 240 CRF patients were randomised Main Diagnosis: COPD (46%) and neuromuscular (23%) diseases, more than 70% with HMV. Groups: no differences in age, diagnosis, mechanical ventilation use or in overall functional status in TM and control group

9. Honorable mention Europe Awards in e-Health European Commission 2003 Brussels The contribution of ICT to eHealth Telemedicine and Homecare eHealth Applications ww.e-europeawards.org eEurope Awards in eHealth Good Practices for Developing a Countrys eHealth Action Plan Runner-up in Health Care Provider category. The 2003 ATSP telehealth awards The Seventh Annual ATSP International Conference September 16-18, 2003 www.atsp.org/about/telehealth_awards.asp Awards

10. Main Projects with Lombardy Region 2002-2005 SUMMA: financed by the Italian Health Ministry (Research Project ex art.12 lett.b D. Lgs. n°502/92) and coordinated by the Lombardy Region/CEFRIEL 2003-2006 CRITERIA : financed by the Italian Health Ministry (Decree of the General Director- Lombardy Region Health D.G. n.15882 on 29 September 2003) and coordinated by the Lombardy Region - Health and Family General Directorates/CEFRIEL 2005-2007 ICP : Programma di riorganizzazione e riqualificazione dellassistenza sanitaria nella città di Milano- authorization Lombardy Region n. VII/18228 19.07.2004 2006-ongoing TELEMACO : financed by the Italian Health Ministry (Decree n° 882 on 30.1.2006) and coordinated by the Lombardy Region. 2006-ongoing Nuove Reti Sanitarie : authorization DGR n.VIII/2471 11.05.2006

11. Unified Second Opinion for General Practitioners Grant: Ministero della Salute (Programma di ricerca ex art.12, lett.b) D.Lgs. n°502/92 Coordinator: Regione Lombardia D.G. Sanità – Programmazione Dicembre 2003 THE SUMMA PROJECT: A FEASIBILITY STUDY ON TELEMEDICINE IN SELECTED ITALIAN AREAS Simonetta Scalvini et al. Telemedicine & E-Health, 2008 in press

12. Services between specialists and GPs Second opinion CARDIOLOGY DERMATOLOGY PNEUMOLOGY DIABETOLOGY RHEUMATOLOGY SERVICE CENTRE ACTIVATION OF THE SERVICE ACTIVATION OF ELECTRONIC PERSONAL HEALTH RECORD COLLECTION/TRASMISSION BIOMEDICAL DATA SPECIALISTS CONSULTING COLLECTION/TRASMISSION OF DATA TO THE SERVICE CENTRE

13. Home care for Chronic Heart Failure in Lombardy Region 2006 20042003 CRITERIA - closed 3 Facilities (2 IRCCS (S. Maugeri, Cardiologico Monzino), 1 AO Busto Arsizio) - N°269 Patients PIANO URBANO - closed 3 Facilities in Milan (AO Niguarda, AO Sacco, AO San Carlo) - N°275 Patients TELEMACO - on going 5 Facilities belonging Districts in Little Towns -N°84 Patients enrolled within 31 March 08 2008 NRS – Nuove Reti Sanitarie - PTS – on going 31 Active health facilities in Lombardy Region- N° 827 Patients enrolled of whom 357 closed on 31 Sept 08

14. Confronti fra Reti Integrate TEcnologiche per gestire al domicilio pazienti post acuti e cronici – RIcerca Applicata Objective: cost-efficacy evaluation of two differnt models of cardiac patients homecare Programma di Ospedalizzazione Domiciliare Riabilitativa (200 post-cardiac surgery patients) Programma di Telesorveglianza Sanitaria Domiciliare (300 CHF patients, NYHA III-IV)

15. D.G.R. 11.05.2006 n° VIII/2471 Programma di Ospedalizzazione Domiciliare Riabilitativa (Home Rehabilitation using Telemedicine) oThe program takes into consideration a period of 28 days as maximum oThe estimated HOMECARE daily cost for patient is 123,00 oThe actual daily fee provided by the Lombardy Region (DRG n°37597 del 24.07.98) for Rehabilitation is 470,00

16. 16 NRS - New health care networks Technological Networks for home care management of post acute and chronic patients comparison – with experimental reimbursement. Rehabilitation post cardio surgery Involved Patients on 06.02.2008 : 227 Involved Hospitals: 4 Home care Telesurvey for chronic heart failure patients Involved Patients on 06.02.2008: 526 Involved Hospitals : 28 www.cefriel.it/NRS

17. Determinazioni in ordine alla gestione del servizio socio-sanitario regionale per lesercizio 2006 Percorso di Telesorveglianza Sanitaria Domiciliare per pazienti con scompenso cardiaco cronico medio-grave 36 Health Facilities Certified for New Models of Management of Cardiologic Diseases 660,00/patient/six months 660,00/patient/six months D.G.R. 11.05.2006 n° VIII/2471

18. 18 TELEMACO Telemedicine for small Municipalities 2005 www.telemaco.regione.lombardia.it Improve services for citizens located in remote areas Reduce the distance between citizen and HC services Assure continuity and quality of care Define indicators for evaluation

19. 19 TELEMACO Health Care Services Home care Telesurvey for CHF or COPD patients Teleconsultation on CAT and video between Hospital for Stroke and trauma Second opinion for GPs (cardio, pneumo, dermato and diabetology) Cardiologic Emergency (technological support) CHF - Chronic Heart Failure COPD - Chronic Obstructive Pulmonary Disease GP – General Practitioners CAT - Computerized axial tomography

20. Telecardiology in Italy: Benefits from a telemedicine network connecting chronic patients, General Practitioners and Health Provider Organisations. The economic impact of extending telecardiology across the whole Lombardy Region, steadily over about six years up to 2012, is material. Much of the investment needed in information and communication technology, electrocardiogram equipment and service infrastructure has already been set in place by Health Telematic Network. The total net benefits are considerable, with an estimated annual benefit cost ratio of more than 3.3:1 by 2012 0 40,000 80,000 120,000 160,000 199819992000200120022003200420052006200720082009201020112012 000s present value of cumulative costspresent value of cumulative benefits

21. Our understanding of market: the future Projects Remb. Operations R&D Projects Remb. Operations R&D Projects Remb. Operations R&D now 2/3 yy 3/5 yy Cash flows from Projects still finance a large amount of operating activities. Probably, it will take 5 years to reverse this structure. Mostly, it depends on the speed of expansion of reimbursment, in terms of number of services and number of types of services.

22. What we actually offer : a strategic development department a professional consultancy department an informatic department developing telemedicine services and biological signals processing dedicated software a scientific research department the management Perspective objectives: to evaluate new outcomes to share the Italian experience with other European realities (meeting/ working groups) to update our knowledge in particular field (i.e cardiology) opening to new strategies of intervention Aims & Objectives

23. Conclusions