The Role of Telemedicine and EHR in Supporting Care Pathways in the Management of Chronic Illness: The Experiences of the Lombardy Region

Nowadays, healthcare systems need to face the growing incidence of chronic diseases and new services have to be planned and managed for elderly people. This work shows how the regional services in the Region of Lombardy (ten million people) have been set to face this challenge. It takes roots from the recent Regional Act that redesigned the organisation of the regional healthcare system and highlighted the importance to “take care” of the chronic patients. As such, the Act promotes the diffusion of clinical pathways and e-health tools, such as telemedicine, that can be used in an efficient way for monitoring the chronic diseases. The paper will look specifically at: The existing healthcare information system, as a new development of the regional health information system (Sistema Informativo Socio Sanitario, or SISS) The services offered by the New Healthcare Networks (Nuove Reti Sanitarie, or NRS) for the remote monitoring of patients affected by CHF and COPD The experience of chronic related groups (CReG), a GP-led integrated service for chronic patients The local hospital units (POT), small local hospitals that have been redesigned to provide medium- to low-intensity health and welfare services It shows how crucial it is to learn from past experiences to identify good solutions for a sustainable and high-quality healthcare system.