1. “Bending the Cost-Quality Curve:
Leveraging mHealth for Home Monitoring and Remote Care”
Dublin, May 13, 2013
How to deliver high-specialty care at home after liver transplantation:
a sustainable approach
Giovanni Vizzini, MD
Department of Medicine - Transplant Hepatology Unit
ISMETT-UPMC
Palermo - Italy

2. Agenda
• A clinical perspective
1. ISMETT-UPMC: a multi-organ transplant center in Palermo (Italy)
2. The clinical patient’s needs after discharge from hospital
3. The limited resources
4. The challenge: Best care at the lower cost
5. The innovative use of available (and simple) technology
6. Clinical Results and Sustainability

3. ISMETT-UPMC in Palermo (Italy)
• ISMETT is a public-private
partnership (The Sicilian Region -
The University of Pittsburgh
Medical Center) situated in
Palermo, Sicily. It is the only
multiorgan (liver, heart, lung, kidney
and pancreas) transplant centre in
Southern Italy.
• We provide high specialty surgical
and non-surgical procedures to the
entire regional population
(approximately 5 million people
living in the Sicilian Region).
• More than 1.300 patients have had
transplants at ISMETT in the last 10
years.
78-bed hospital

4. Solid organs transplant recipients: a growing population
12
27
49
40
58
91
104
150 146
127 131
118
135 133
0
20
40
60
80
100
120
140
1601999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
ISMETT: 1378 transplants from July 1999 to Dec 2012

5. Solid organs transplant recipients: a growing population
12
27
49
40
58
91
104
150 146
127 131
118
135 133
0
20
40
60
80
100
120
140
1601999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
ISMETT: 1378 transplants from July 1999 to Dec 2012
Every year, 120-130 new
patients in follow up
At present, more than one
thousand of transplant
recipients in follow up at
ISMETT

6. Patients’ Needs
• In the early post-transplant period, the need to maintain tight clinical
follow up results in prolonged time of hospitalization or, alternatively,
forces patients (still in not optimal conditions) to travel frequently
BUT
• approximately one third of patients live in the city area (about one million
inhabitants), while two third of them live in other areas of the Sicilian
Region or outside Sicily. The distances between Palermo and other Sicilian
cities vary from 100 to more than 250 Km.
and
• the state of the road network and other communication routes is not
optimal and it represents a problem in maintaining a strict and continuous
follow-up in the post-transplant period

7. Patients’ Needs
Liver transplantation at ISMETT- Palermo
Patients survival curve

8. Patients’ Needs
Liver transplantation at ISMETT- Palermo
Patients survival curve

9. Patients’ Needs
What we usually do in the early post-operative course
The early post-transplant period is
crucial due to:
High risk of rejection
High risk of infections
High risk of drug toxicity
The rigid clinical surveillance is mandatory, in order to obtain:
• early diagnosis of clinical complications
• correct dosage of immunosuppressive medications
• best compliance with therapy
Liver transplantation at ISMETT- Palermo
Patients survival curve

10. Patients’ Needs
What we usually do in the early post-operative course

11. Patients’ Needs
What we usually do in the early post-operative course
For these reasons, the usual approach of the Transplant
Centers is to force patients to stay in hospital or in
residences near the hospital for a long time after
transplant or, alternatively, to travel frequently (back and
forth from home)

12. Patients’ Needs
• In the early post-transplant period, the need to maintain tight clinical
follow up results in prolonged time of hospitalization or, alternatively,
forces patients (still in not optimal conditions) to travel frequently
BUT
• approximately one third of patients live in the city area (about one million
inhabitants), while two third of them live in other areas of the Sicilian
Region or outside Sicily. The distances between Palermo and other Sicilian
cities vary from 100 to more than 250 Km.
and
• the state of the road network and other communication routes is not
optimal and it represents a problem in maintaining a strict and continuous
follow-up in the post-transplant period

13. Distance (Km of highway) between the ISMETT venue (Palermo)
and the major sicilian cities

14. Palermo to:
Trapani  107 Km
Agrigento  126 Km
Caltanissetta  127 Km
Enna  136 Km
Palermo to:
Catania  207 Km
Messina  237 Km
Ragusa  248 Km
Siracusa  259 Km
Distance (Km of highway) between the ISMETT venue (Palermo)
and the major sicilian cities

15. Best care at the lower cost:
Recommendations of Institute of Medicine

16. Best care at the lower cost:
Recommendations of Institute of Medicine

17. Best care at the lower cost:
Recommendations of Institute of Medicine

18. The innovative use of available (and simple) technology
Post liver transplant “Home-monitoring”.
The solution:
we teamed-up with Intel-GE Care Innovations TM to design a study
using its tele-health technology with the aims of
 speeding up hospital discharge of post-liver transplant patients
 enabling uninterrupted recovery at home
 maintaining close contact with our medical teams
The technology allows nurses and physicians
 to monitor and support transplant patients from their homes
 to check their general condition
 to collect biometric data
 to manage their treatment
to offer face to face appointments via video conferencing.

19. The innovative use of available (and simple) technology
Post liver transplant “Home-monitoring”.
The solution:
we teamed-up with Intel-GE Care Innovations TM to design a study
using its tele-health technology with the aims of
 speeding up hospital discharge of post-liver transplant patients
 enabling uninterrupted recovery at home
 maintaining close contact with our medical teams
The technology allows nurses and physicians
 to monitor and support transplant patients from their homes
 to check their general condition
 to collect biometric data
 to manage their treatment
to offer face to face appointments via video conferencing.
The challenges:
To remotely manage patients
- in the aftermath of an extremely invasive surgical
procedure
- in not complete stable conditions
- still suffering of the consequences of a prolonged
disease

20. Post liver transplant “Home-monitoring”
Study protocol
Inclusion criteria:
All consecutive adults patients
who live in Sicily, who received
liver transplantation at ISMETT
and were discharged from July 15,
2011.
Staff involved:
At the patient’s home:
technician for the instalment of the
devices
In Tele-Visit (tele-consult):
Physician (ISMETT-UPMC)
Transplant coordinator (ISMETT)
Others(physical th.- psycologist)
Clinical pathway:
• Clinical monitoring during the post-
discharge time (first 3 months or
until clinical stabilization)
• Verification of the adherence to
therapy (immunosuppression,
other medications)
• Verification of the adherence to
the bio-humoral surveillance after
transplant

21. Post liver transplant “Home-monitoring”.
Main functionalities:
Monitoring of vitals signs, according to a pre-defined schedule
(that depends on the time from transplantation) or to the patient’s
clinical conditions.
Tele-visit (by Videoconference patient home-ISMETT)
performed by our specialists:
once a day during the first week
each other day during the first month
every week until conclusion of the study (3 months)
whenever considered useful according to the clinical needs
Educational support for patient/family

22. Post liver transplant “Home-monitoring”at ISMETT-UPMC
Patient information/
education
Phone line
Internet
3G wireless
Transplant Physician
Transplant Coordinator
HomeTransplant Center

23. Post liver transplant “Home-monitoring” at ISMETT-UPMC

24. Post liver transplant “Home-monitoring” at ISMETT-UPMC

25. Post liver transplant “Home-monitoring” at ISMETT-UPMC

26. Post liver transplant “Home-monitoring”.
Study end-points
In Home-monitoring
July 2011-April 2013
Hystoric controls
July 2009-June 2011
Patients included 74 75
Patients in the analysis (> 3 months of f-up) 66 75
Average length of stay (days) 19.8 25.4
Deaths during the 3-month study period 0 1
Patients who needed urgent re-admission during the first
3 months after transplant
0 3
Overall number of urgent re-admissions during the first 3
months after transplant
0 4
Overall length of stay due to urgent re-admissions during
the first 3 months after transplant (days)
0 25
Patient/family satisfaction rate (based on questionnaire
administered)
98% NA

27. Economic impact of the home-monitoring system at ISMETT-UPMC
Data:
– Length of stay reduction of 6 days (average) in the group of
patients in home-monitoring
– Number of liver transplant recipients discharged from our
Centre: 60-70 per year
– Cost of hospital stay (no-ICU) in our organization: about 1.000
Euro per day
– Cost of home monitoring: 7 Euro per patient/day
Saving
Six days of hospital stay x 60
patients = 360 days of hospital
stay
360 days x 1000 Euro =
360.000 Euro/year
Cost
7 Euro per patient/day
Total cost of home monitoring
per patient: 7 euro x 90 days =
630 Euro
630 Euro x 60 patients =
37.800 Euro/year

28. Follow-up of liver transplant recipients: a “sustainable” approach
Sustainability
Social To guarantee that precious resourses used for the care are used
appropriately = Best standard of care for patients
Economic Rational use of high-cost resources (hospital beds/OPC visits by
specialists).
Reduction of unnecessary assistance-related costs (i.e. work-days of
family members)
Environmental Reduction of the impact to the enviroment (i.e. reduction of fuel
consumption for travel and related CO2 production)
A possible solution to the challenges we face:
home-monitoring/tele-consult

29. How to deliver high-specialty care at home after liver transplantation:
a sustainable approach
Conclusion
- The adoption of this simple technical solution has allowed
us to maintain an effective clinical and therapeutic
remote management in a group of patients discharged
from the hospital after a liver transplantation 
 Best care at the lower cost, according to the
recommendations of The Institute of Medicine:
Partner with patients
Use Information Technology more effectively
Decrease waste and increase efficiency
- The result can be considered a “proof of concept”:
home-monitoring seems to be a safe and effective
solution not only in stable “chronic” patients, but also in
unstable patients with difficult issues in the clinical and
therapeutic management

30. Thank you
Giovanni Vizzini, MD
Department of
Medicine
ISMETT-UPMC
Palermo- Italy
gvizzini@ismett.edu
www.ismett.edu