Telemedicine in Covid time: balances and future prospects

The health emergency from Covid 19 highlighted the fundamental role assumed by telemedicine in reshaping patient management, guaranteeing continuity of care at home even for chronic patients not affected by the coronavirus.  

In fact, during the pandemic, healthcare started from the territories and identified the home as the first place of care, and although telemedicine services began to spread in Italy well before the 2020-2021 period, the emergency situation required organisational changes and the adoption of new technologies very quickly. 

Health in the PNRR

It is therefore not surprising that in the National Recovery and Resilience Plan, the document that illustrates the proposals for the allocation of Italian resources of the Next Generation EU, approved on 22 June 2021 by the European Commission, there is a chapter devoted to ‘Proximity networks, facilities and telemedicine for territorial healthcare’. The aim is to promote a coordination between health and social services that allows “to really achieve full autonomy and independence of the elderly/disabled person at home, reducing the risk of inappropriate hospitalisations”.

The patient represents, in fact, the fulcrum of the new modality of supplying health services at a distance and there are numerous advantages to be found in the exploitation of these services, such as greater equity in access to care, improved interaction between doctors and the community, a reduction in travel, sometimes very complicated for frail individuals, and a consequent reduction in the costs borne by the sick.   

According to the ‘National Guidelines in Telemedicine sanctioned in the 2014 State-Regions Conference’different types of services can be identified in the field of telemedicine, which can be categorised according to the type of outpatient activity and the interactions carried out remotely. In particular, we speak of telehealth, teleconsultation, telehealth, telemonitoring and teleassistance by health professions.  

Indeed, it must be emphasised that telemedicine systems must be integrated precisely with the ‘Guidelines’ in order to actually become part of every patient’s daily clinical practice.  

We met with Stefano Dalmiani Professor of the Master in eHealth Management at Rome  Business School  to take stock of the issue, analysing successes, critical issues and future prospects, and he told us:

“In our country, the urgency of the Covid 19 pandemic has made the telemedicine experience permanent: it has acted as a sort of catalyst and amplifier of existing, albeit isolated, experiences in many Italian regions. In just a few weeks, the National Health Service was able to establish a new intervention paradigm.   

Admittedly, patients initially responded in an uncertain manner because they were used to having physical contact with health workers. Subsequently, the approach with telemedicine became increasingly empathetic, also thanks to an increase in trust towards their smartphones and computers that potentially allow them to remain in direct contact 7/7 – h24 with their doctor, who often provided them with feedback almost in real time. However, it should be emphasised that although telemedicine has been widespread in Italy for about three decades, it is still a very fragmented experience throughout the country.

Reorganisation, design and development of technological solutions

The PNRR, in Mission 6 concerning Health, identifies a substantial investment plan also intended for the modernisation and development of strategies for the progressive improvement of the public health supply, amounting to 15.63 billion euro, i.e. 8.16% of the 191.5 billion euro envisaged by the Plan as a whole, with the important aim of building integrated digital infrastructures throughout the country.  

In Italy, a very ambitious programme for the reorganisation of the health system based on new technologies has begun, where IT support is indispensable. A rigorous planning of activities will be necessary to achieve the objectives: first and foremost, that of levelling out the inequalities that currently exist between the different regional healthcare systems. An important element of the reorganisation is related to the redefinition of quality, structural, and technological standards for hospital care, in order to guarantee homogeneous levels of hospital care throughout the country, both in terms of the adequacy of the structures and in terms of the human resources employed. 

Today, we have an enormous amount of information that can support the system, but which often remains confined within individual systems or processes. The key for several years now has been communication and sharing: as far as information systems are concerned, we speak of inter-operability; as far as human resources are concerned, we speak of co-operability.  In both scenarios, bottom-up and top-down communication in specific areas is crucial.” 

Health in Italy 

The identification of best practices is based on the analysis of the various indicators present in the performance evaluation system. Their history is ancient: in fact, the first significant examples of evaluating the results obtained from care practices date back to the early 1900s.   

The evolution of statistical science and epidemiology has allowed best practices to find a formal framework in the more general context of the evaluation of health services and systems, assuming a systemic character. 

Our National Health System, established in 1978, is considered by the World Health Organisation to be one of the best structured systems in the world. In spite of this, important regional differences are observed. In general, from the point of view of the use of technology, we can certainly speak of best practices in Lombardy, Veneto and Emilia Romagna. Tuscany also ranks very well for healthcare as a whole and for having healthcare companies of excellence in various specialities, such as cardiology at the Gabriele Monasterio Foundation, the facility where I work.

Then of course there are also excellencies in other regions such as ApuliaSicily and Lazio: unfortunately they are isolated experiences and not put into a system. This is the Italian problem: valuable experiences are often not transferable to other realities or regions, and the excellences remain happy islands

Privacy and e-health

The development of information technologies in the health field must be able to combine the protection of citizens’ sensitive data with the efficiency and effectiveness of the medical services provided. In fact, e-health, through organisational models with a high technological content, is able to raise the quality of the services offered to the population, which must place its trust in the security measures adopted to protect citizens’ personal information.

When we talk about e-Health, it is essential to address the complex issue of the security of sensitive patient data. A high level of security integrity must always be ensured to guarantee the rights of the data subject.  Privacy is currently governed by the European regulations set forth in the GDPR, the General Data Protection Regulation, and its Italian declination, and it requires that the entire system evolve with total respect for personal and sensitive data, and as a member of the European Union, Italy will be able to play an important role in directing the appropriate choices for the delicate management of health information, also with a view to its use for research purposes.”

STEFANO DALMIANI

He graduated in computer science from the University of Pisa in 1989 and worked in the field of programming languages; from 1995 to 2000 he worked in the military and defence sector as an analyst and developer of military defence systems. In 2000, he left the military sector to join the Bioengineering and Medical Informatics group of the National Research Council.Thanks to his experience in the design and development of e-health systems, he became head of the CNR hospitals’ central electronic medical records system and responsible for EMR software developments. In 2008, he moved to the CNR/Regione Toscana “Gabriele Monasterio” Foundation (FTGM), a public health and hospital research company, as head of the ICT department, responsible for information systems management and in charge of the ICT research area for translational bioinformatics and clinical informatics. During this period he was a member of the commission for the “Common Medical Record” of the Italian Ministry of Health, member of the ICT commission of the Italian Ministry of Health, member of the commission for the regional EHR of the Region of Tuscany, member of the management of ProREC Italy, member of the management of APIHM (Privacy and Information Healthcare Manager Association), president of WG HL7 Italy CDA R2 Discharge Summary. He is a lecturer in numerous courses on eHealth standards and systems modelling, and author of over 80 publications in international journals, conference scientific papers, books, and journal articles.

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