A VIRTUOUS IMPLEMENTATION of TELEMEDICINE SERVICES in RHEUMATOLOGY: DESCRIPTION of CHANGE MANAGEMENT PRACTICES ADOPTED by the NIGUARDA HOSPITAL

Background: Over the past few decades there have been an increasing debate around the use of telemedicine. Despite this, there is still a slow rate of adoption of telemedicine services. According to a recent scoping review this may be due to a piecemeal approach to the change process, and a lack of understanding of how to plan, manage and reinforce change when implementing telemedicine service1. A virtuous example of implementation of telemedicine services can be found within the rheumatology unit of Niguarda Hospital in Milan (Italy), where the whole staff has been involved in experimenting with new multichannel interactions to communicate with patients for more than a decade. Developed in 2011 with the introduction of the iAr Plus app for the collection of Patient Reported Outcomes (PROs), the project was first targeted to patients with Rheumatoid arthritis, Pso-riatic arthritis and Spondylarthritis. In 2019 the project consolidated and added the home delivery of biological drugs for the stable patients. During spring 2020, this experience was further enhanced and extended to all patients treated with biological drugs to facilitate patient interaction during Covid-19 and was characterized by three elements: remote monitoring, triage through phone calls and home delivery of medication. What contextual factors and mechanisms adopted to plan, manage, and reinforce change where more successful? Objectives: This study aimed to highlight what were the distinctive and successful elements of this implementation experience, what we could learn from it, and which managerial implications we could derive for future implementations. Methods: We adopted a realist evaluation approach2 to identify the underlying generative mechanisms that explain 'how' the outcomes were caused and the influence of context. Thus, we deepened how the change management process has been managed by conducting semi-structured interviews with the unit director, and the staff members involved in the phases of the project (i.e., clinicians, nurses, and administrative staff). The interviews were recorded and analyzed through an ad-hoc framework1 for the analysis of change management practices. This framework identifes 10 change steps divided into 13 strategic practices and 6 operational practices that are important during the preparatory phase of the change process, for managing the change, and to sustain and reinforce longterm change. Results: Our study identifed the most relevant actions put in place by the rheumatology unit during the three major steps of preparing for change (e.g., developed telemedicine App, assigned coordinating role, identifed champions), managing change (e.g., developed and articulated a clear vision, provided training, developed ownership), and reinforcing change (e.g., continued to engage partners). The analysis highlighted four main lessons learned: frst the characteristics of the context and a strong managerial structure were a prerequisite for success. The generative mechanisms that explain how these successful outcomes were caused are: a leadership role able to defne a clear vision and a clear specialization of tasks and roles;the involvement of all team members;regular meetings and interactions. Second, patients should be involved as central actors in the defnition of the care pathway. The fnal decision on the kind of services to be used was made by the patient. Third, the relevant stakeholders should be involved since the co-design of the app. Finally, change should be incremental. The Rheumatic unit introduced one change at a time, and this brought to constant improvements. Conclusion: The framework adopted can be used either to retrospectively analyze the experiences developed but may also act as a tool to guide future tele-medicine service implementation and research. As well as the lessons learned can guide the implementation of future telemedicine experiences.

JOINING TELEMEDICINE SERVICES in RHEUMATOLOGY: The ROLE PLAYED by PERSONALIZED EXPERIENCE from PATIENTS' PERSPECTIVE

Background: With the beginning of the Covid-19 pandemic, many hospital departments worldwide, including rheumatology ones, were forced to implement telemedicine strategies. Telemedicine revealed to be an umbrella term, with various practical implementations and different degrees of pre-paredness1. Some practitioners were already familiar with telemedicine, as in the case of the Rheumatology Unit of ASST Niguarda Hospital in Milan (Italy), where telemedicine projects have been implemented for more than a decade with structured design and organized processes. Moreover, patients in Niguarda have experimented telemedicine with personalized mixes of channels, including e-mails and phone calls, Patient Reported Outcomes questionnaires, and home delivery of drugs. This represents a paradigmatic case study that enables us to deepen essential questions on the success of telemedicine. Objectives: Given that the last decision on joining telemedicine rests with patients2, we decided to adopt their perspective. We deepened three main aspects: i) the benefits perceived, ii) the willingness to enrol in future projects, iii) the preference on the service-mix, i.e., on-distance contacts rather than in-person visits. Most importantly, we investigated differences in the three areas among all patients based on the type of personalized experience had. Methods: We conducted a survey from November 2021 to January 2022, enrolling randomly outpatients who attended the rheumatology unit for any reason. The survey originated from well-known surveys, such as the Tele-Health Usability Questionnaire3 and the Intention to use telehealth services4. However, we decided to overcome the usual separation that makes surveys addressed either to users or no users of telemedicine. Our survey comprised an introductory set of questions related to personal, social, clinical and ICT skills information, followed by the central part on telemedicine, which explored the three areas mentioned: benefits, adherence, preferences on service-mix. For this part, questions were the same for all patients apart from the tense used, being conditional tense for no-users and past tense for users. All the answers were analysed with descriptive statistics and regression models. Results: A complete response was given by 400 patients: 71% were female, 59% were 40-64 years old, 53% of them declared to work, and the diseases most represented were Rheumatoid Arthritis (36%) and Osteoporosis/arthrosis (21%). The descriptive statistics revealed interesting differences between users and no users, e.g., the desire to participate in future projects was stated by 95% of users, 81% of no users. These results were confrmed by multivariate logistic regression models that controlled for the influencing patients' characteristics (such as being old or a frequent hospital attender). It emerged that no-users imagined wide-ranging benefits. As for the willingness to participate to future telehealth projects, even if personal characteristics showed an impact (e.g., being a worker increased the probability to adhere), other things being equal, having had a more intense experience of telemedicine increased the odds of accepting by 3.1 times (95% C.I. 1.04-9.25), compared to no users. Furthermore, the more telemedicine was experienced, the higher the willingness to substitute in-person with online contacts. Conclusion: Our study contributes to enlighten the crucial role played by the telemedicine experience in determining patients' preferences. On one side, users appeared more aware of the realistic benefts to be expected from telemedicine. On the other side, it seemed that the more telemedicine was experienced, the higher the willingness to adhere to future projects and to increase on-distance contacts.

Transformation of Cancer Care during and after the COVID Pandemic, a point of no return. The Experience of Italy.

Policymakers everywhere struggle to introduce therapeutic innovation while controlling costs, a particular challenge for the universal Italian National Healthcare System (SSN), which spends only 8.8% of GDP to care for one of the world's oldest populations. Oncology provides a telling example, where innovation has dramatically improved care and survival, transforming cancer into a chronic condition. However, innovation has also increased therapy duration, adverse event management, and service demand. The SSN risks collapse unless centralized cancer planning changes gear, particularly with Covid-19 causing treatment delays, worsening patient prognosis and straining capacity. In view of the 750 billion Euro "Next Generation EU", released by the European Union to relieve Member States hit by the pandemic, the SSN tapped a multidisciplinary research team to identify key strategies for equitable uptake of innovations in treatment and delivery, with emphasis on data-driven technological and managerial advancements - and lessons from Covid-19.

Il doppio binario delle cure primarie. Alcune scelte di fondo per i sistemi di tutela della salute

What role did primary care and general practice play in the different phases of Covid-19 epidemic? What can we learn from the emergency to innovate the health system and the role of primary care in our country? The article addresses these questions by presenting the happenings that directly involved primary care and general practitioners (especially on topics concerning USCA, personal safety and protection, and new care models) and by making some considerations on the immediate future. The role of general practice is discussed from a double perspective, where the epidemic situation coexists with the ordinary care management, especially of chronic patients. The management of the pandemic forces us to reflect on i) the coordination of territorial actors, ii) the management of territorial services network operations, iii) the consequences of challenging the traditional care model, and iv) the hypothesis of a new mix of person-centred services and community centred-services. Copyright © FrancoAngeli.

Alcune riflessioni prima di tirare le somme

The current crisis is an unprecedented global challenge in terms of its health, economic, social, and geopolitical impact. More than 4 billion people in over 100 countries are living in some sort of lockdown. Each country has chosen its own strategy, adopting a variety of measures in an attempt to fight an unparalleled menace. Although it will take time to draw conclusions on what are the key factors for success in this battle, several preliminary lessons can be learned from those countries that were forced to face the emergency before others. But before assessing, some distinctions should be made First: the pandemic is an episodic phenomenon that shocked regional health systems in Italy. Don’t mistake emergency for normality (the synecdoche risk): regions most affected by the SARS-CoV-2 have a really good quality health care services but unfortunatly helpless to respond in an age of pandemic. Getting it wrong might be the way for learning from mistakes (not for destroying what can still be useful). Second, decisions in a great uncertainty scenario should be changed quickly as in a video game (videogame rationality). Third, our SSN is a resource not only a cost. By acknowledging the central importance of the healthcare system in society, the cost-containment policies of the last few decades that have been waged on healthcare systems around the world need to be reconsidered. By acknowledging the central importance of the healthcare system in society, the cost-containment policies of the last few decades that have been waged on healthcare systems around the world need to be reconsidered. Warnings of the risks of such policies have been neglected for too long. The current epidemic has demonstrated that debilitated healthcare systems can be brought to the brink of collapse with unforeseen consequences for the entire society. Copyright © FrancoAngeli.