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Integrated management of patients with chronic diseases

Patients with chronic diseases constitute an increasing proportion of the population and a significant burden on the budgets of western world healthcare systems. ICT can offer tools to people involved in the management of the care and welfare, which allow more effective communication and integration of different levels of management, support to decision-making and increase of the autonomy of patients. The challenge of the integrated management  lies in the poly-centric, articulated nature of the chronic care management, which changes over time. General medicine, hospital services,  specialized structures, the primary social network and, last but not least, the patients themselves contribute to the patient care in various modalities. The Unit aims to analyze the different levels of care and assistance to identify needs, and implement and evaluate appropriate tools to support existing processes. The systems implemented will be subjected to multidisciplinary assessment. The forms of interaction mediated by a prototype system will be evaluated by quali-quantitative methods proper of the social sciences to investigate the forms of appropriation and evaluate possible changes of directions of development. The mature systems (e.g., diary and tele-monitoring in type 1 diabetes) will be evaluated with clinical trials conducted in provincial structures. The Unit will support a qualitative analysis of the trials.


The research will proceed along different lines:

  • Analysis of the support of the social network and of the primary caregivers. This action aims to understand the role and investigate the practices of family support in the management of chronic illness. The research work is conducted using qualitative methods of social research and concerns the management of complex therapies in elderly patients and the support of the family and caregivers to patients with type 1 diabetes.
  • Remote monitoring and remote assistance. The use of the TREC platform provides a real-time communication channel between patients and healthcare professionals allowing an evaluation of disease parameters and possible support interventions. The Unit will continue the research on new forms of patient-physician interaction in the domains of type 1 diabetes, heart failure and pediatric asthma. The TreC platform will also be used in the project CCM_2012 to implement in the real-world scenario of the Italian SSN (Servizio Sanitario Nazionale) the continuity of care for complex patients remotely controlled.
  • Systems supporting the empowerment of the patient. The Unit will implement systems for patients to support the management of their health/disease condition based on rules defined with the clinicians,  as well as educational tools on mobile devices related to healthy lifestyle for patients with type 1 diabetes.
  • Formalization and exploitation of medical knowledge used in "smart" customizable applications for the integrated management of chronic patients. These actions follow the two main streams of the research in the field of medical knowledge management carried on in the Unit: the analysis, implementation and use of specialized medical terminologies and common terms vocabularies, and the analysis, modeling, and use of clinical and organizational knowledge in ontologies and formal models of guidelines, treatment plans and rules, and in formal models of the processes of shared and multidisciplinary care.