The implementation of the Telbios platform and Microsoft technologies for CRM in healthcare enables general practitioners in the four cooperatives that operate in the Local Health Authorities in Lombardy (Bergamo, Como and Milan) to assist chronic
patients. The system is part of the CReG (Chronic Related Group) project, which provides a number of disease management services centred around patient care, home telemonitoring and educating and empowering chronically ill patients. The objective of the program
is to transform the traditional passive health care in active one through a program that focuses on prevention and control that improves the quality of life of the patient and drastically reduces hospitalization costs. At the present time there are 306 General
Practitioners involved in the 4 cooperatives for a total of approximately 37.000 patients followed under the program.
The project, known as CReG (Chronic Related Group), which the Regione Lombardia implemented for health care to deal with situations related to prevention and health care for chronically ill patients, is aimed at ensuring the continuity of assistance and
the appropriate care for each patient, guaranteeing better clinical care, the most appropriate instruments for home telemonitoring as well as the most effective services to support patients and their families, in order to delay the worsening of the illness
as long as possible.
||This project is revolutionary in its simplicity, because through computer instruments and remote services, it coordinates “home care” and disease management activities and intervenes proactively, updating patients and their families,
creating a strong link with family doctors, preventing acute phases of the illness and consequently reducing hospitalization costs.
| Renato Botti
One of the latest developments in this project is the role that has been assigned to the cooperatives constituted by the General Practitioners, which becomes a new subject ‘provider’ within the National Regional Health System, which must guarantee a number
of services defined in the health care project to the Local Health Authorities involved (Bergamo, Como, Milano). For the realization of the project the General Practitioners can avail themselves of technological and organizational services, designed and developed
by Telbios. The principal pathologies covered at the present time in the project are chronic obstructive pulmonary disease (COPD), heart failure, diabetes type 1 and 2, hypertension, ischemic heart disease, osteoporosis and neuro-muscular pathologies.
The platform that Telbios, specialized in disease management services, developed for the General Practitioner cooperatives for the CReG project was realized by the software house Santer Reply utilizing the Microsoft Dynamics CRM technological platform.
The solution helps to create, on a computer and management level, the right approach among three separate and distinct activities:
- Coordination between patients and their family doctors;
- Adherence to and compliance with the patient’s health care program and the telemonitoring of the patient’s health;
- Information to support the patients and their families.
The solution is based on Microsoft Dynamics CRM developed personalization and constitutes the first customization realized in Italy for the health and welfare sector aimed at services for chronically ill patients.
Using a web-based interface, General Practitioners can access the platform and examine the data for each patient and create personalized health care plans for said patient and, on the basis of international guidelines relating to the management of the chronically
ill, the frequency of visits and the therapies to follow, define and set timeframes and doses for prescribing drugs. At the same time, the solution enables operators and nurses with the Telbios Service Center and/or present in the General Practitioners’ offices
throughout the territory to examine the health care plan that each individual patient needs to follow. In addition to being able to consult personal data for each patient and their relevant health care program, the computer platform also automatically creates
the “to do” list controlled by the operators at the Service Center who monitor procedures and who use outbound telephony services and integrated VoiP technology. Each telephone call with the patient updates the patient charts with Microsoft Dynamics CRM and
transfers useful information to the physician for a clinical evaluation. “This project is revolutionary in its simplicity – states Renato Botti, Managing Director of Telbios – because through computer instruments and remote services, it coordinates “home care”
and disease management activities and intervenes proactively, updating patients and their families, creating a strong link with family doctors, preventing acute phases of the illness and consequently reducing hospitalization costs”.
||These processes are part of a broader approach to health care for persons afflicted with chronic pathologies, based on proximity and active health care. They provide a service close to the patient, avoiding inappropriate access to
specialized structures and consequently reducing certain costs associated with health care.
| Fiorenzo Corti
Family Doctor General Practitioner and Lombardy Regional Secretary
Activities that can be programmed with Microsoft Dynamics CRM include controls on the quantities of drugs available to patients, verifying that the correct drug dosage has been taken and controlling that tasks assigned to the patient for the activities involved
in the home telemonitoring (periodic weighing, measuring blood pressure, oxygen levels in the blood, sugar, etc.) have been completed. “These processes – states Fiorenzo Corti, General Practitioner and Lombardy Regional Secretary of FIMMG – are considered
in a broader vision of health care for persons afflicted with chronic pathologies, based on proximity and active health. They provide a service that is close to the patient, avoiding inappropriate access to specialized structures and consequently reducing
certain costs associated with health care. Thanks to the partnership between Telbios and the cooperatives that adhere to the “Buongiorno Creg” project, the services and technologies made available and implemented at the patient’s home will improve activities
aimed at prevention and obtain immediate feedbacks. Thanks to the transfer of data acquired remotely, we realize if problems arise and a follow-up visit is required. All of this not only renders the patient responsible for his/her care but forestalls the worsening
of a pathology, improving the patient’s health and consequently reducing costs for hospital procedures due to the worsening of the illness”.
“The infrastructure that utilizes Microsoft Dynamics CRM, thanks to the support offered by the Service Centers, enables General Practitioners to avail themselves of a number of instruments to move from passive health care to proactive health care, to coordinate
activities on behalf of the patient, to prepare personalized health care according to the patient’s health at any given moment.” says Renato Botti, Managing Director of Telbios.
“There are approximately 37,000 patients enrolled in the CReG project and managed with the integrated Telbios – Microsoft platform – continues Botti – while 306 General Practitioners utilize it. This means that it is a high-impact project, with a significant
patient-base and initial volumes, that bear witness to the solidity and benefits of the solution”. The platform, in fact, is the basis for the direct link between patients, the Telbios Service Center and General Practitioners. The solution manages the information
and clinical data relating to the chronic patients who adhere to the initiative, providing physicians with all the information they need to program therapies and health care and evaluate them over time. As the general population ages, this project helps to
mitigate the economic impact on the Regional and National Health Care System of the costs involved in treating chronic illnesses. “The greatest advantage reached concerns the level of assistance and quality of the health care services offered to chronic patients”,
sustains Fiorenzo Corti. “General Practitioners in our region are able to offer more in terms of assistance to their patients since until now they were not in a condition to provide state-of-the art diagnostic solutions, principally due to regulatory and contractual
restraints. This tele-health care and telemonitoring project instead enables them to find the appropriate operating space in the regulatory framework to guarantee diagnostic services within the area of primary health care. Patients will benefit from more effective,
precise and appropriate therapies, precisely because they have been observed and prescribed according to shared, proactive and no longer reactive regulations, furthermore measurable over time”.
From an integration point of view, at the present time the Telbios platform is not connected to the regional CRS-SISS, but steps have been taken so that this can be realized, perhaps at the end of the CreG project experimentation, thus facilitating a real
extension of the program on a broader level. “The infrastructure that utilizes Microsoft Dynamics CRM – concludes Botti – enables General Practitioners, thanks to the support provided by the Service Centers, to have at their disposal a series of instruments
to actually move forward from passive health care to active care, to coordinate activities on behalf of the patient, to prepare personalized health care plans according to the patient’s health at any given moment, in order that the patient adheres to this
program and by so doing generates a better quality of life for all and savings for the population”.
Microsoft Dynamics is a line of integrated, adaptable business management solutions that enables you and your people to make business decisions with greater confidence. Microsoft Dynamics works like familiar Microsoft software such as Microsoft Office, which
means less of a learning curve for your people, so they can get up and running quickly and focus on what’s most important. And because it is from Microsoft, it easily works with the systems that your company already has implemented. By automating and streamlining
financial, customer relationship, and supply chain processes, Microsoft Dynamics brings together people, processes, and technologies, increasing the productivity and effectiveness of your business, and helping you drive business success.
For more information about Microsoft Dynamics, go to:
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