REVIEW

CURRENT
OPINION Electronic health (e-Health): emerging role
in asthma
Matteo Bonini

Purpose of review
Asthma is the most prevalent chronic respiratory disease and represents a relevant socioeconomic burden.
e-Health has the potential to improve disease control and adherence to treatment in asthmatic patients.
Available data are, however, scarce and inconsistent limiting the use of e-health in clinical practice. This
article aims to provide a systematic review of the literature published in the last year regarding the real
place and impact of e-health in the management of asthma.
Recent findings
Despite few conflicting results, collected findings support a beneficial effect of e-health on asthma
management and control, as well as positive patients’ acceptance and satisfaction. Included studies mainly
assessed m-health, telemedicine, electronic health record and digital app interventions, in both adults and
children. Existing evidence appears however to be only of moderate quality and high heterogeneity was
found in the study endpoints and designs.
Summary
There is the need to establish widely adopted standards for conducting trials and reporting results in e-
health. These should include minimal clinical difference assessment and prevent potential pitfalls such as
patient privacy protection, data fishing and lack of compliance of interventions with evidence-based
medicine, guideline recommendations and regulatory board statements.
Keywords
adherence, asthma, electronic health, information technology, management

INTRODUCTION phenotypes and endotypes [7,8]. Asthma manage-

Asthma is the most prevalent chronic respiratory
disease, with an incidence increasing over the recent
decades [1]. It is estimated that more than 300
million people worldwide currently have asthma
&&
[2 ]. Asthma therefore represents, in both adults
and children, a relevant socioeconomic burden in
terms of mortality, morbidity, quality of life and
healthcare costs [3,4]. According to current guide-
lines, optimal asthma management should aim to
early diagnosis and treatment strategies should tar-
get to optimization of lung function, minimization
of symptoms and prevention of exacerbations [2 ].
&&
However, despite extensive availability of effective
therapies, a considerable number of patients do not
manage to achieve satisfactory disease control [5].
Patient adherence has been shown to represent a
crucial link between effective treatment and
improved disease outcomes. However, recent stud-
ies revealed significant underuse of asthma therapy
[6]. Furthermore, it has long been recognized that
asthma is a heterogeneous disease including distinct
ment, therefore, needs to be particularly timely,
accurate and patient tailored in order to be properly
effective. This complex and multiparametric
approach would also significantly benefit the inter-
ventions for patient education and involvement [9].
Electronic health (e-health) is a relatively recent
concept, dating back to late 1990s [10]. Oh et al. [11]
defined e-health ‘an emerging field at the intersec-
tion of medical informatics, public health and
business, referring to health services and infor-
mation delivered or enhanced through the Internet
and related technologies’, although they found 51
National Heart and Lung Institute (NHLI), Imperial College London &
Royal Brompton Hospital, London, UK
Correspondence to Dr Matteo Bonini, MD, PhD, Imperial College London
& Royal Brompton Hospital, National Heart and Lung Institute (NHLI),
Airways Disease Section, Dovehouse Street, London SW3 6LY, UK.
Tel: +44 7889635702; e-mail: m.bonini@imperial.ac.uk
Curr Opin Pulm Med 2017, 23:21–26
DOI:10.1097/MCP.0000000000000336

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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Asthma
KEY POINTS
 Asthma is the most prevalent chronic respiratory
disease and represents a relevant
socioeconomic burden.
 e-Health is an emerging field at the intersection of
medical informatics, public health and business that
covers different areas of intervention and encompasses
a wide variety of subdomains.
 e-Health has the potential to enhance the quality of
care in asthmatic patients.
 Collected evidence is of moderate quality but supports
a beneficial effect of e-health on asthma management
and control, as well as a high degree of patients’
acceptance and satisfaction.
 There is the need to establish widely adopted standards
for conducting trials and reporting results in e-health.
different descriptions for it in their systematic
review. Independently from the definition adopted,
e-health mainly covers three areas of intervention:
first, the delivery of information, for health pro-
fessionals and consumers, through Internet and
telecommunications; second, the use of infor-
mation technology to improve public health serv-
ices; third, the use of e-commerce and e-business
practices in health systems management. e-Health
also encompasses a wide variety of subdomains such
as digital apps, telemedicine, mobile health, virtual
healthcare teams, electronic health records (EHRs),
medication trackers and clinical decision
support systems.
In today’s society, e-health plays an essential
role in revolutionizing healthcare and providing a
mainstream tool to assist patients in self-monitoring
and decision-making [12,13]. e-Health has, indeed,
the potential to enhance the quality of care,
improve adherence to therapy and allow early detec-
tion of disease worsening by continuous monitoring
and real-time feedback to patients. e-Health strat-
egies have been already shown to be effective in the
management of a variety of chronic diseases such as
hypertension, chronic heart failure and diabetes, by
enabling patient empowerment and behaviour
changes [14–16]. Moreover, there is an increasing
demand from patients for using electronic-based
solutions in dealing with their diseases [17]. None-
theless, the use of e-health is becoming widespread
in healthcare industry and research. Because many
of these aspects are relevant also for patients with
chronic respiratory diseases, it has been recently
suggested that there is a role for e-health in the
management of asthma. e-Health might in fact
22 www.co-pulmonarymedicine.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
empower patients with tools and skills to become
adequate self-managers, thereby improving control
over their disease. Furthermore, healthcare pro-
fessionals may find e-health valuable to interac-
tively support patients and facilitate contacts and
information exchange. Lastly, e-health might ena-
ble proactive care, for example by providing easy-to-
use and personalized asthma action plans especially
for those patients who do not respond to standard
treatment and are at higher risk of exacerbations.
Although many e-health strategies have been
developed and tested, there are scarce and incon-
sistent data on their real role and effectiveness in
asthma management. Due to this lack of evidence e-
health interventions are not yet widely adopted in
daily clinical practice [18].
The aim of this article is to provide a state-of-the-
art systematic review of the literature published in
the last year regarding the place and the impact of e-
health in the management of asthma.
Electronic searches were undertaken in Medline,
Web of Science (ISI) and The Cochrane Library
(CENTRAL) databases. The registers were searched
for articles published in the last year, using the key-
word ‘asthma’ combined with the term ‘electronic
health’ and related Medical Subject Headings
(MeSH). Original studies written in English and
primarily addressing the role of electronic health
in asthma were considered eligible for being
included in the present review. Reference lists of
included studies, recent reviews and websites were
also screened for further relevant records.
RESULTS
The search strategy yielded 64 articles. After having
removed duplicates, manuscripts potentially
relevant for the aim of the review were selected
on the basis of their titles and abstracts and retrieved
in full for careful assessment. Ten manuscripts ful-
filled the review inclusion criteria and are discussed
in detail below (Fig. 1).
The goal of the study performed by Johnson
&
et al. [19 ] was to assess the impact of a website
and short messaging service (SMS) reminder system
(MyMediHealth) on medication adherence and self-
management in adolescents with asthma. Eighty-
nine subjects, referring to an academic outpatient
setting, completed a randomized-controlled trial.
Adolescents who were assigned to MyMediHealth
(n ¼ 46) were asked to create a medication schedule,
and accordingly received SMS reminders for 3 weeks.
In the other arm, control subjects received action
lists as a part of their usual care. Main outcome
measures included website usage patterns and self-
report of system usability, medication adherence,
Volume 23  Number 1  January 2017

Studies identified by the
search strategy
64
Studies selected on the
basis of title and/or abs.
and retrieved in full
24
Studies included in the
systematic review
10
Randomized controlled
trials
3 6
FIGURE 1. Search strategy flow-chart.
asthma control, self-management and quality of
life. Participants reported high satisfaction with
MyMediHealth. Compared to controls, improve-
ments were found in self-reported medication
adherence, quality of life and self-management.
The level of system usage was however
extremely heterogeneous.
Koufopoulos et al. [20] conducted a 9-week
randomized-controlled trial to assess whether an
online community intervention could improve
adherence to asthma therapy. Two hundred and
sixteen British asthmatic adults, who had been pre-
scribed an inhaled corticosteroid (ICS) treatment,
were recruited and assigned to either an online
community ‘AsthmaVillage’ or a simple diary sup-
port for recording ICS use. Participants were
required to report the number of drug doses taken
in a post. Those randomized to the online com-
munity were allowed to read the posts of the other
members and reply to them, while control subjects
could not visualize and actively interact with others’
comments. The primary outcomes were represented
by self-reported medication adherence and objec-
tive adherence to the intervention (i.e. number of
visits to the website). Results obtained showed that
self-reported adherence to asthma therapy was not
significantly different between groups in both
intention-to-treat and per-protocol analyses. More-
over, website use was higher in the control arm.
Accordingly, the authors concluded that joining an
online community was not useful to improve medi-
cation adherence in asthma patients.
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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Electronic health (e-Health): emerging role in asthma Bonini
Studies excluded
14
Non original (9)
Non primarily addressing asthma (5)
Prospective and Pilot study published
retrospective studies as abstract
1
The effectiveness of e-health strategies has been
also assessed in reducing the use of short acting beta-
2 agonists (SABA) and improving asthma control.
&
The study of Merchant et al. [21 ] reports about a
telemedicine solution (Propeller Health) for facili-
tating appropriate patient self-management by pro-
viding a data-driven feedback and personalized
educational guidance. In details, a FDA-approved
sensor objectively monitored the use of inhaled
medications, capturing date, time and number of
uses, and then transmitting the information via
Bluetooth to a paired smartphone app that recorded
the location of the event and securely uploaded data
to remote servers. A total of 495 patients were
enrolled in parallel arms for 1-year monitoring of
SABA use. Patients in the intervention group
received access to and feedback from the Propeller
Health system. Routine care patients were as well
outfitted with sensors, but did not receive any feed-
back. Compared with control subjects, the Propeller
Health system study arm significantly decreased
SABA use and increased SABA-free days. Further-
more, despite Asthma Control Test (ACT) scores
not being significantly different between groups
in the whole study population, patients with
initially uncontrolled asthma showed a greater
improvement in the interventional arm.
An abstract presented at the last American Acad-
emy of Allergy, Asthma & Immunology (AAAAI)
Congress investigated the impact of a mobile health
asthma programme on use of rescue medication,
frequency of asthma-free days and disease control
www.co-pulmonarymedicine.com 23
Asthma
[22]. Adults and children (n ¼ 299) with asthma and
a current prescription for SABA were enrolled in a
prepost pilot study. Participants initially received an
electronic inhaler sensor, which tracked the date,
time, and geographic location of rescue medication
use. Following a 1-month control period to assess
baseline levels of asthma control and SABA use,
participants were then given access to smartphone
and web-based applications providing individually
tailored and guideline-based education about their
asthma activity. By the end of the study, rescue
inhaler use declined by 75% and the proportion
of asthma-free days increased by 39%. Moreover,
the proportion of participants with well-controlled
asthma and who reported having an asthma action
plan improved over the course of the intervention.
A sample of 20 adolescents (12–16 years) with
persistent asthma was recruited from North Caro-
lina paediatric practices and was asked to use two
asthma apps over a 1-week period [23]. Through
semi-structured interviews, participants reported
that quizzes, reminders and charting features
increased their ability to self-monitor and -judge
their health status which, in turn, helped them to
manage their asthma independently and keep it well
controlled. Adolescents also expressed an interest in
sharing app data with their family members and
healthcare providers, fostering increased communi-
cation about asthma and enhancing social support
to better deal with their condition.
In a proof-of-concept study, 60 adult asthmatics
with poorly controlled asthma (i.e. at least two events
of emergency care need over the past year) were
enrolled to test, over a 4-month period, a smartphone
app (Scripps Asthma Coach) specifically designed to
improve asthma control by providing individualized
and timely support to patients [24]. The Asthma
Control Test was used as primary endpoint to assess
disease control over intervention. A retrospective
chart review was also used to evaluate changes in
lung function and prescribed courses of systemic
corticosteroids. Fifty-eight of 60 patients completed
the final survey, reporting high satisfaction. Patients
showed a significant improvement in ACT scores
over the study period. Concurrently, there was a
7.9% absolute increase in FEV1, while systemic cor-
ticosteroids decreased from 0.5 to 0.3 courses.
Authors concluded that study findings reinforced
the growing body of evidence supporting that smart-
phone apps are an effective and accessible tool to
improve asthma control when used regularly.
In a prospective cohort study, an EHR-based
communication process was implemented to
increase the proportion of parents referring to
primary care providers (PCPs) instead of using emer-
gency departments as source of asthma care for their
24 www.co-pulmonarymedicine.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
children [25]. Parents of 50 children aged 2–12 years
were enrolled. Compared to baseline, at both 3 and 6
months after intervention, a significantly higher
number of parents reported that they were identify-
ing the PCP as the principal asthma healthcare pro-
vider and were referring their children to the PCP
when experiencing problems with their asthma. As
stated by authors, these observations could encour-
age families to increase PCP visits thereby improving
their children’s longitudinal asthma monitoring and
reducing healthcare costs.
The retrospective analysis of Matiz et al. [26]
aimed to evaluate the impact of information tech-
nology tools on the outcomes of asthmatic patients
aged 4 to 18 years. Changes to the EHR included
modifications to notes, care plans, and prescrip-
tions. Of the study population (n ¼ 1217), 65%
had a classification of asthma severity and 63% were
risk-stratified. Seventy percent had at least a control
assessment. Care plan use increased from 5% to 22%
and enrolment in care coordination increased from
0.1% to 4%. After 3 years, there was also a reduction
in emergency department and inpatient admissions
for asthma.
The feasibility of using a patient portal for paedi-
atric asthma in primary care, its impact on manage-
ment, as well as barriers and facilitators of success
was evaluated through a mixed-method imple-
mentation study in 20 clinical practices [27]. Parents
of asthmatic children, aged 6–12 years, identified
via EHR, were asked to complete on the portal
monthly surveys to communicate treatment con-
cerns and goals, symptom control, medication use
and side-effects. A logistic regression was used to
evaluate the association of portal use with child
characteristics and changes to asthma management.
Furthermore, 10 clinician focus groups and 22 semi-
structured parent interviews explored barriers and
facilitators of portal use. Among the 9133 families
invited, only 237 (2.59%) used the portal. Children
of parents who used the portal were significantly
more likely than nonusers to be younger (6–9 years),
have mild or moderate/severe asthma, a prescription
of a controller medication and a private insurance.
In addition, portal users with uncontrolled asthma
had significantly more medication changes and
primary care asthma visits compared with the
previous year. The authors concluded that despite
the potential for real benefits to communication
and child health outcomes, the results of the study
suggest that achieving high levels of portal adoption
is yet unlikely.
Despite the growing market of e-health disease
self-management tools, few studies have reported
the presence of teen patients in all phases of product
design. Sixteen young asthmatics were, therefore,
Volume 23  Number 1  January 2017

invited to evaluate two existing asthma apps for 7–
10 days [28]. At the end of the trial period, detailed
interviews were conducted with each participant to
gather insights about user experience. Participants
wished for further educational asthma-related
contents and more compelling interface features,
also suggesting improvements in symptom and
medication tracking.
In addition to the papers selected through the
search strategy run in the electronic databases, the
screening of further sources allowed to identify an
ongoing study aimed to develop an asthma
monitoring system using an innovative e-Health
approach (http://www.myaircoach.eu/). MyAir-
Coach is a multicentre Horizon 2020 EU funded
project started in 2015. One of the main goals of
the research study is to help patients to optimally
manage their asthma by increasing the awareness of
their clinical status and the adherence to medical
treatments through a personalised and user-friendly
m-Health strategy. MyAirCoach sensors will
monitor and store several physiological, behaviou-
ral and environmental parameters which will be
crossed with asthma data. Thanks to sophisticated
analyses and computational modelling techniques,
the MyAirCoach system will then deliver measure-
ments, features, and personal profiles to obtain a
detailed and actual picture of the patient’s con-
dition. This will hopefully, in the near future, also
provide clinicians early indications of increasing
asthma symptoms or exacerbations and support to
understand the mechanisms underlying the pro-
gression of the disease.
CONCLUSION
Despite few conflicting results, collected findings
overall support a significant beneficial effect of e-
health on asthma management and control. The
judgement of patients’ acceptance and satisfaction
towards interventions evaluated was also found to
be positive. Included studies were performed in both
adults and children and mainly addressed interven-
tions based on m-health, telemedicine, EHRs and
digital apps. Existing evidence appears, however, to
be only of moderate quality, being in many cases
hampered by the adopted study designs. In fact, out
of the 10 included studies, only 3 were randomized-
controlled trials, while 6 were either longitudinal or
retrospective investigations and one was a pilot
study. Furthermore, except for this last research
reported as an abstract in the Journal of Allergy and
Clinical Immunology, all other papers were published
in medium-low ranked journals (mean impact fac-
tor: <4). Extremely high heterogeneity was also
found in the study endpoints, which were ranging
1070-5287 Copyright ß 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Electronic health (e-Health): emerging role in asthma Bonini
from asthma control, to use of rescue medication,
hospital admissions, treatment adherence, disease
self-management, quality of life, patient satisfaction
with the intervention, etc. With this regard, it needs
to be addressed that in many cases study endpoints
were recorded only through self-reporting. Lastly,
the lack of a proper study power assessment and the
difficulties in establishing a minimal clinical differ-
ence especially for the patient-reported outcomes
(PROS) makes it even harder to compare and inter-
pret study findings. There is, therefore, the need to
establish widely agreed and adopted standards for
conducting trials and reporting results in e-health.
These should also take into consideration potential
pitfalls related to e-health interventions such as
patient privacy protection, data fishing and lack
of compliance with evidence-based medicine,
guideline recommendations and regulatory board
statements.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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READING
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& of special interest
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Volume 23  Number 1  January 2017