1. Sergio Guillén, Maria Teresa Meneu, Riccardo Serafin, Maria Teresa Arredondo, Elena Castellano, 2010

2. With 50–80% of all global health spending related to chronic diseases, health systems that maintain current disease management practices cannot afford to continue caring for the escalating numbers of people with chronic diseases DM models of care may be a systematic approach to coordinating health care interventions across levels

3. DM supports the physical practitioner/patient relationship and plan of care emphasizes prevention of exacerbations and complications through the use of evidence-based practice guidelines evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health e-DM - supported by the intervention of Information and Telecommunication Technology

4. HeartCycle e-DM solution to serve both Heart Failure (HF) and Coronary Heart Disease integrating care at home with professional care in the hospital multi-parametric monitoring of vital signs, analysing the data and providing automated decision support, to derive therapy recommendations

6. Scenarios Rehabilitation - recover body functions compromised by the disease Maintenance - keep patients within certain ranges to reduce or avoid medium-long term negative consequences Preventing Deterioration - avoid or reduce the severity of a new crisis, which will provoke short term damage

7. User requirements Patient - maintaining their quality of life and making their life easier reducing their feeling of being ill Professionals - know much information about their patients and focus their attention in those patients in need for more support Organizations - a sustainable way to better manage the increasing number of chronic patients with an optimal usage of the resources and the different care levels.

8. System Architecture Medical Response Centre Self-Care Management Unit DM Planner & Assessment Education & Social connection Logistic & Maintenance

10. Implementation SCMU - wireless monitoring devices, mobile PC MRC - J5EE web application accessed by the professional, also holds patient’s current care plan DMPA – another supporting web application with graphical editors to create complex evaluation rules E&SC - in-house content management system which provides access to certified medical knowledge customized on the bases of the medical profile