Background:
The current guidelines for glaucoma management suggest that patients perform a mean of three eye examinations per year associated with functional/structural exams. However, most of the primary territorial centers (ASL) are not equipped with the instruments for glaucoma diagnosis/follow-up. Therefore, these tests are carried out exclusively at the secondary specialized referral centers leading to a progressive overcrowding of the structure, increasing in waiting times and difficulties in ensuring an adequate continuity of care for glaucoma patients.

Methods:
we analyzed the current territorial and hospital outpatient activity in order to find critical areas, specific problems and needs. The project will embrace two phases: definition of the network and digital platform and creation of a “point of care (POC)” physically located within the ASL and managed by the secondary referral center. The POC will be equipped with all the instruments required for the complete follow-up of the stable glaucoma patients.

Results:
The digital platform provides a strong connection between the healthcare infrastructures both on the administrative, technical and clinical level allowing to share clinical patients’ data including the exams’ results. The actors involved will provide, through the platform, all the clinical patients’ data necessary to send stable patients from the secondary referral center to the POC or to send cases that require para-surgical/surgical managment or specialistic evaluation from the ASL to the secondary referral center. The visit or further diagnostic tests will be scheduled online, through a shared agenda, with a significant reduction of the waiting list allowing to schedule the periodic follow-up based on the individual risk level.

Conclusion:
The integrated digital network could improve the patient management, the effectiveness and efficiency of the healthcare system ensuring the continuity of care for the management of chronic-degenerative disease.