In the last years, multidisciplinary post-discharge treatment programs, such as telemonitoring, have been promoted as a strategy for Heart Failure (HF) management. However, the distinctive requirements that a telemonitoring system should have, have not been clearly identified. To this aim, the most relevant requirements for telemonitoring of HF patients are derived from evidence-based Clinical Practice Guidelines (CPGs) for HF management. The main objective of this work is to present a prototype of a telemonitoring system for HF patients, named SiTe iC, that has been developed based on the identified requirements, highlighting its design and evaluation.

A first prototype of the system was designed and programmed. It consists of an mHealth app for HF patients, a website for physicians who monitor patients, and a server which runs an Application Programming Interface to allow communication between the app and the website.

The system was thoroughly assessed through a clinical trial that demonstrates that telemonitoring using SiTe iC actually improves patients self-care when compared to usual care and it has the potential to avoid patient re-hospitalizations.

This study demonstrated that the identified functional requirements for telemonitoring systems are relevant. In addition, thanks to SiTe iC, HF patients would take a more active role in their disease management by improving self-care.

在过去的几年中，已经推广了多学科的出院后治疗计划，例如远程监护，作为心力衰竭（HF）管理的策略。但是，尚未明确确定远程监视系统应具备的独特要求。为此，对HF患者进行远程监护的最相关要求来自HF治疗的循证临床实践指南（CPG）。这项工作的主要目的是提出一种用于心衰患者的远程监护系统原型，名为SiTe iC，该原型是根据已确定的要求开发的，着重强调了其设计和评估。

系统的第一个原型被设计和编程。它包括一个用于HF患者的mHealth应用程序，一个用于监视患者的医生的网站以及一个运行应用程序编程接口以允许该应用程序与该网站之间进行通信的服务器。

该系统已通过一项临床试验进行了全面评估，该试验表明与常规护理相比，使用SiTe iC进行远程监护实际上可以改善患者的自我护理，并且可以避免患者再次住院。

这项研究表明，已确定的远程监控系统功能需求是相关的。此外，由于采用了SiTe iC，HF患者将通过改善自我护理而在疾病管理中发挥更积极的作用。