Expert Review of Respiratory Medicine

ISSN: 1747-6348 (Print) 1747-6356 (Online) Journal homepage: http://www.tandfonline.com/loi/ierx20

The role of tele-medicine in patients with

respiratory diseases

Nicolino Ambrosino & Claudio Fracchia

To cite this article: Nicolino Ambrosino & Claudio Fracchia (2017): The role of tele-
medicine in patients with respiratory diseases, Expert Review of Respiratory Medicine, DOI:
10.1080/17476348.2017.1383898

To link to this article: http://dx.doi.org/10.1080/17476348.2017.1383898

Accepted author version posted online: 25

Sep 2017.
Published online: 27 Sep 2017.

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 EXPERT REVIEW OF RESPIRATORY MEDICINE, 2017
https://doi.org/10.1080/17476348.2017.1383898

REVIEW

The role of tele-medicine in patients with respiratory diseases

Nicolino Ambrosino and Claudio Fracchia
Istituti Clinici Scientifici Maugeri, Istituto di Montescano IRCCS, Pneumologia Riabilitativa, Montescano (PV), Italy

ABSTRACT ARTICLE HISTORY

Introduction: Tele-medicine is a clinical application connecting a patient with specialized care con- Received 3 August 2017
sultants by means of electronic platforms, potentially able to improve patients’ self-management and Accepted 20 September 2017
allow for the care of patients with limited access to health services. This article summarizes the use of KEYWORDS
tele-medicine as a tool in managing patients suffering from some pathological respiratory conditions. Tele-monitoring; Tele-
Areas covered: We searched papers published between 1990 and 2017 dealing with tele-medicine and rehabilitation; Ehealth; COPD;
respiratory diseases, chronic obstructive pulmonary disease, asthma, interstitial lung disease, chronic Sensors; Asthma; Interstitial
Downloaded by [Australian Catholic University] at 18:20 27 September 2017

respiratory failure, neuromuscular diseases, critical illness, home mechanical ventilation, and also legal lung diseases; Chronic
and economic issues. Controlled trials report different results on feasibility, cost-effectiveness, and respiratory failure; Ventilator
safety of tele-medicine. assisted individuals;
Neuromuscular diseases
Expert commentary: Progress in tele-medicine widens the horizons in respiratory medicine: this tool
may potentially reduce health care costs by moving some medical interventions from centralized
locations in to patient’s home, also allowing for the delivery of care in countries with limited access
to it. Legal, safety, and privacy problems, as well as reimbursement issues, must still be defined and
solved. At present time, we still need much more evidence to consider this modality as a real option in
the management of these patients.

1. Introduction pulmonary disease (COPD), asthma, interstitial lung diseases

(ILD), chronic respiratory failure (CRF), neuromuscular diseases
Increased life expectancy of the worldwide population results
(NMD), critical illness, ventilator-assisted individuals (VAIs),
in high prevalence of chronic diseases, as well as of ‘chroni-
home mechanical ventilation (HMV), and home-based rehabi-
cally critical’ patients including those suffering from respira-
litation (tele-rehabilitation) [8,12–15]. This article summarizes
tory diseases [1]. As a consequence, the traditional hospital-
the use of tele-medicine as a tool in managing patients suffer-
centered health care systems of developed countries suffer
ing from some respiratory pathological conditions.
from increasing costs, worsened also by citizens’ unrealistic
expectations in the age of welfare state reforms [2,3]. Also low-
and lower-middle-income countries, with limited access to 2. Method
care, have to meet the increasing health care requests from
We searched randomized controlled trials (RCT), observational
their citizens [4]. To reduce costs for and optimize the health
studies, systematic reviews, and meta-analyses published
care delivery, a potential solution may be the use of wearable
between 1990 and 2017 in English in PubMed, and Scopus
technologies allowing for the care of some patients far from
data bases using the keywords: ‘Tele-medicine AND: respiratory
usual locations, such as hospitals or outpatient clinics [5].
diseases, COPD, asthma, interstitial lung disease, chronic
Tele-medicine is a clinical application connecting a patient
respiratory failure, neuromuscular diseases, critical illness,
with specialized care consultants, by means of electronic plat-
home mechanical ventilation, legal issues, economics’; ‘Tele-
forms [6] and has been defined as ‘Distribution of health
rehabilitation AND COPD’.
services in conditions where distance is a critical factor, by
health care providers that use information and communica-
tion technologies (ICT) to exchange information useful for 3. Technical issues
diagnosis where doctor is able to perform diagnosis at dis-
Many devices are used in tele-medicine such as wearable
tance’ [7]. Increasing application of ICT to health care and
sensors and smartphone applications (apps), miniaturized pro-
advances in wearable and data transmission technology have
cessors, body area networks, and wireless data transmission
allowed for tele-medicine programs [8,9], potentially useful to
technologies to assess physical, physiological, and biochemical
improve the delivery of care as well as the patients’ compli-
parameters in different environments at rest and during activ-
ance to chronic management [10,11]. Use of tele-medicine has
ities (Table 1) [9,16]. These devices can be used in different
been proposed and reported, among others, in chronic heart
interventions such as real time or ‘store and forward’ video or
failure, diabetes, stroke, behavioral health, staff education and
telephone links to-from patients and care-givers, Internet-
training, and primary care as well as in chronic obstructive

CONTACT Nicolino Ambrosino nico.ambrosino@gmail.com Istituto di Montescano IRCCS, Pneumologia Riabilitativa, Montescano, Italy
© 2017 Informa UK Limited, trading as Taylor & Francis Group
 2 N. AMBROSINO AND C. FRACCHIA
Table 1. Examples of devices and activities used in tele-medicine for respiratory
diseases.
Devices Activities
Sensors (activity trackers, smart Vital signs and physiological data
watches, smart clothing, patches, such as respiratory rate, breathing
tattoos, body area networks) pattern, minute ventilation heart
rate, pulsossimetry, capnography,
physical activity, air quality
Transmitters from medical equipments Data such as tidal volumes and
airway pressures delivered by
mechanical ventilators, spirometry
Transmission modalities Telephone lines, sms, e-mail, video
phones, websites or mobile
phones, video-conferencing
Medical devices programmed at Mechanical ventilators
distance
Dedicated Internet softwares
based tele-communication, digital, broadband, satellite, wire-
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less or Bluetooth transmission to-from patient [7,11,17].
Smartphones are used worldwide, independent of geogra-
phical or economical conditions; therefore, smartphone apps
may be useful tools [15]. Between 2011 and 2013, the number
of commercial ‘medical’ apps more than doubled, but their
usefulness for doctors and patients is still being debated: 50%
of apps served as information sources only and 24% served as
simple electronic diaries [18].
4. Indications
4.1. Chronic obstructive pulmonary disease
The role of tele-medicine in COPD patients is still being
discussed [19]. Benefits have been reported in systematic
reviews and meta-analyses even in severe patients with
comorbidities [20,21]. In a controlled study [22], patients on
long-term oxygen therapy (LTOT) were assigned either to
home tele-assistance or usual care. Patients in the tele-med-
icine group measured their vital signs on a daily basis, and
data were transmitted to a clinical monitoring center for
follow-up and to a pneumologist in the case of clinical
alert. In the intervention group, after a 7-month follow-up,
compared to controls, there was a significant reduction in
emergency room visits, hospitalizations, length of hospital
stay, need for non-invasive ventilation (NIV), and a significant
increase in the time to the first severe exacerbation. There
was no drop out due to technology, and patients were
satisfied with the program [22]. Tele-collaboration between
primary care and lung function professionals resulted in
improvement of the quality of spirometry performed by
non-professionals [23]. An RCT of tele-assistance program
for CRF patients including COPD resulted in reduction in
hospital admissions, general practitioner calls, and costs
[24]. In a retrospective study, a tele-assistance program
alone reduced the exacerbations rate of patients on LTOT,
with greater effectiveness, when added to long-term NIV [25].
A small 12-month RCT suggested that home tele-monitoring
of oximetry, temperature, pulse, electrocardiogram, blood
pressure, spirometry, and weight with telephone support
and home visits resulted in reduction in hospital and emer-
gency department admissions, and hospital length of stay as
compared with telephone support and home visit only [26].
However, other studies did not confirm these positive
results [27,28]. In a 6-month crossover RCT in patients with
chronic respiratory diseases, the addition of tele-monitoring to
standard care did not improve the time to the next hospitali-
zation or health related quality of life (HRQL), whereas it
increased hospital admissions and home visits [29]. A systema-
tic review did not find any evidence for the effectiveness of
telephone follow-up alone or with other tools in reducing
readmissions [30]. Another systematic review reports that
only three studies fulfilling high quality criteria found signifi-
cant improvements in HRQL [31].
4.2. Asthma
Management of asthma includes decision-making based on
patient’ symptoms, environmental exposures, and medica-
tion use. Improving patient’s adherence to treatment and
self-management is crucial for quality and success of care
and to reduce the overall costs. Controlled trials have inves-
tigated the feasibility, cost-effectiveness, and safety of tele-
medicine in asthma self-management [14,17,32–34]. A pro-
spective, controlled study in outpatient clinics investigated
whether a self-care system would achieve better asthma
control through a mobile telephone-based interactive pro-
gram [17]. Compared with controls, significantly increased
peak expiratory flow rates during a 6-month follow-up, bet-
ter HRQL after 3 months, and fewer exacerbations and
unscheduled visits were observed in the mobile telephone
group [17]. A systematic review and meta-analysis from
three RCTs using different technologies reported improve-
ment in asthma control, though the clinical effectiveness
varied regarding the used apps, typically incorporating mul-
tiple features [35]. Initial findings from the Asthma Mobile
Health Study performed by means of smartphones detected
increased reporting of asthma symptoms in regions affected
by heat, pollen, and wildfire [36]. These data included daily
self-reported symptoms, symptom triggers, and real time
geographic location information potentially useful to predict
adverse outcomes such as exacerbations or hospitalizations.
However, evaluation of data from app users was difficult due
to inter- and intra-patient differences in each user’s response
rates over time, and non-overlapping periods of enrolment
among different users. To obviate these problems, a promis-
ing probability imputation model to infer missing data has
recently been proposed [37].
4.3. Interstitial lung disease
Given the availability of new drugs, functional follow-up is
important in ILD, nevertheless there are few studies of tele-
medicine in this field. Following an earlier study of self-mon-
itoring [38], a study investigated the reliability, feasibility, and
impact of home-based measurement of forced vital capacity
(FVC) and dyspnea. Patients performed weekly home-based
assessments of FVC and dyspnea using a mobile hand-held
spirometer and self-administered dyspnea questionnaires.
Mean adherence to weekly assessments over 24 weeks was
greater than 90%. Compared with baseline and 24-week only,
weekly assessments of FVC resulted in increased precision and

power [39]. Nevertheless, the usefulness on clinical outcomes
must still be evaluated.
4.4. Neuromuscular diseases
NMD are associated with several limitations which may be
improved by tele-medicine systems. These include muscular
weakness associated with functional impairment and depen-
dence, the slow but unstoppable development of CRF, and
exacerbations [40]. The feasibility of tele-assistance for NMD
patients with impaired cough capacity was assessed in a pilot
study [41]. Patients’ respiratory signs and symptoms were
recorded at home and transmitted to a remote control center:
chest physiotherapy was prescribed and modulated accord-
ingly, resulting in reduced hospitalizations and emergency
room admissions [41]. In a long-term (15 years) retrospective
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evaluation [42], elderly patients including those with NMD
with comorbidities underwent a tele-medicine program tai-
lored to their specific disease. Interventions of nurses and
specialist second opinions accounted for 39–82% and
12–27% of the activities, respectively [42]. In another study, a
tele-medicine system based on video-conferencing and tele-
monitoring of cardiorespiratory variables was used over a
period of 5 years, evaluating variables such as the use of the
system, patient satisfaction, and clinical impact. The total hos-
pital admissions decreased [43]. The use of tele-medicine may
be even more relevant in NMD patients under HMV [7].
4.5. Critical illness and HMV
Tele-medicine programs in the intensive care unit (Tele-ICU)
are expected to implement a high-intensity staffing model in
relatively underserved areas like the rural ones [44,45].
Although controlled studies are still inconclusive, there are
promising reports [46]. The ICU Tele-medicine Committee of
the Society of Critical Care Medicine reviewed development
and outcomes of tele-ICU programs: in the United States for-
mal tele-ICU programs supported 11% of critically ill adult
patients in non-federal hospitals resulting in lower ICU and
hospital mortality and shorter length of stay [47]. The
American College of Critical Care Medicine includes tele-ICU
among the models of care for critical patients [48].
Critically, ill patients undergoing mechanical ventilation in
an ICU for longer than 21 days have high in-hospital mortality
and greater post-discharge mortality, health care utilization,
and costs compared with patients undergoing mechanical
ventilation for a shorter period of time [49]. Due to advances
in management and related lower ICU patients’ mortality and
morbidity, the prevalence of VAIs is increasing, varying from
6.6 to 23 per 100,000 [50–52]. These patients have poor out-
comes, despite high medical resource consumption [53]. The
different models of care [7,54] should be evaluated in the
organization model frame of comprehensive management of
these patients in each country. The need to reduce costs and
to improve safety suggests the development of tele-monitor-
ing programs for VAIs, still to be evaluated [7]. A survey on
HMV users’ perception of care provision across Europe [55]
reported that about half of respondent patients would be
confident with a tele-monitoring system of their HMV
EXPERT REVIEW OF RESPIRATORY MEDICINE 3
program. Unfortunately, another international survey on pat-
terns of home NIV use in COPD patients reported that tele-
medicine was only an option for 5% of respondents [55,56].
In summary, COPD is the most frequently treated respira-
tory condition by means of tele-medicine programs. The con-
flicting results need more evidence. Even more evidence is still
required in other respiratory diseases.
4.6. Tele-rehabilitation
Exercise training-based pulmonary rehabilitation is suggested
for the vast majority of COPD patients [57] especially in the
light of the global pandemic of physical inactivity and million
deaths per year associated with it [58]. The wide use of smart-
phones with accelerometry apps to measure physical activity
identified inequality in activity distribution within countries
[59]. Although the beneficial effects of pulmonary rehabilita-
tion are well established, patients’ needs still remain largely
unmet. Major barriers to provision and/or completion of pul-
monary rehabilitation programs include, among others, costs
of organization, travel and transport problems, disruption to
routine, inconvenient timing, and lack of social support [60].
Delivery of tele-rehabilitation programs has been suggested as
a means to solve these problems.
Advances in sensor technology over recent years have
resulted in the availability of miniaturized accelerometers for
new activity monitors. These devices are not only able to
record the sedentary time, but also to quantify activities like
walking, running, cycling, and even to distinguish different
postures [9]. Pedometers and accelerometers are used in
tele-rehabilitation to meet relevant organizational problems
and resources consumption [9,13,14,61]. It has been shown
that supervised home training and counseling may be safe,
feasible, and beneficial for severe COPD patients [62]. Home-
based maintenance tele-rehabilitation was found to be equally
effective to hospital-based, outpatient, maintenance pulmon-
ary rehabilitation, in reducing acute exacerbations and hospi-
talizations and the risk for emergency department visits [14].
Another study showed that tele-rehabilitation improved
endurance exercise capacity and self-efficacy in patients with
COPD when compared with usual care [63]. Nevertheless, a 7-
to 10-week study did not find any significant improvement in
COPD patients equipped with a tablet compared with stan-
dard rehabilitation [64]. The amount and intensity of physical
activity can be significantly increased in patients with COPD
using a 12-week semi-automated tele-coaching intervention
including a step counter and a smartphone app [65]. A recent
study has proposed a system combining a wearable photo-
plethysmogram device and a motion-sensing camera [66].
Derived respiratory and physical exercise motions were
detected in real time by photoplethysmography. Patients’
physiological data and exercise characteristics were automati-
cally logged into a remote management server to be moni-
tored and analyzed by a medical professional either in real
time or at a later time [66]. In an RCT, a 6-week program of
online-supported pulmonary rehabilitation was non-inferior to
a conventional model delivered in face-to-face sessions in
terms of effects on exercise capacity and symptom scores,
and was safe and well tolerated [67]. A systematic review
 4 N. AMBROSINO AND C. FRACCHIA
and meta-analysis found that tele-monitored pulmonary and
cardiac rehabilitation had similar benefits to usual care, with
no adverse event [68]. An interactive web-based program was
considered feasible and acceptable when compared to stan-
dard pulmonary rehabilitation [69]. On the other hand, an RCT
of telephone-mentoring with home-based walking which pre-
ceded rehabilitation showed no benefit in exercise capacity of
COPD patients [70].
In summary, tele-rehabilitation may be potentially useful to
deliver programs in environments that are difficult to reach
and to maintain benefits of standard programs. Nevertheless,
we need more RCT to clearly establish the clinical benefits as
compared to standard rehabilitation.
5. Legal issues
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Legal and insurance coverage issues have not been solved yet.
As with any medical act, tele-medicine may face legal pro-
blems such as misunderstanding in tele-consultation between
patient/family and staff or among health operators; unin-
tended or fatal consequences of equipment failure [71]; viola-
tion of privacy due to lack of protection or manipulation of
data; safety issues and related malpractice claims with difficult
distinction of responsibilities, and potential obligations among
care-givers [7]. With the increasing diffusion of this technol-
ogy, law cases will increase, but still lack shared international
and national solutions [72,73].
5.1. Devices and technology
Many wearable devices have not been characterized in terms of
reliability, measurement accuracy, safety, and efficacy nor have
any mark of conformity, such as from the European Union (EU)
or Food and Drug Administration (FDA), with the applicable
requirements of regulatory laws [74]. In the framework of EU
law, tele-medicine is considered, simultaneously, as a health
service and an information service; therefore, both regulations
may apply [75]. The EU highlighted the need of regulatory
frameworks to ensure tele-medicine promotion and produced
some important directives [76]. In the USA in 2012, Congress
passed the FDA Safety and Innovation Act, leading to agencies
collaboration on existing technology and emerging innovations
in tele-medicine and on appropriate regulation of use [77–79].
5.2. Licensure
In a report from the American Telemedicine Association [80]
comparing physician practice standards and licensure for tele-
medicine by state, barriers to its implementation were identi-
fied as 1) limiting definitions of physician–patient encounters,
2) requirements related to the presence of a tele-presenter on-
site during tele-medicine encounters, 3) additional require-
ments of patient informed consent, 4) limited licensure port-
ability/reciprocity across state lines, and 5) limitations related
to internet prescribing. Some states of the Union require a
dedicated license for providers to practice [81].
5.3. Privacy
Privacy is a primary concern [82]. The present legislations may
protect patients’ data from third-party access when a health
care provider or consumer uses a health app, but it may not
protect against the access to data by the developer of a
private health app. The possibility of privacy violation should
encourage health care providers to adopt data security poli-
cies minimizing the risk. There are national standards to pro-
tect individuals’ electronic personal health data requiring
appropriate administrative, physical, and technical interven-
tions to ensure the confidentiality, integrity, and security.
Nevertheless, privacy violations are still a difficult problem to
solve, and European and American legislations are still work-
ing on it. This issue should be managed by default while
building the system of data transmission rather than with
late corrections.
5.4. Safety
Safety and potential malpractice claims are equally important
and difficult to solve. The main problem is the identification of
responsibilities among different actors, like health profes-
sionals, technical providers, or even the devices themselves.
A potential solution to all the above problems might be the
appropriate relationship between patient and professionals
driven by the informed consent, requiring a clear explanation
of medical and technical issues [82].
6. Economics
6.1. Cost-effectiveness
Reports of cost-effectiveness are inconsistent and often
obtained from poor quality studies. As a consequence, deci-
sion-makers may have difficulties in accepting tele-medicine
programs in heath systems. A meta-analysis reported a
reduction in hospital costs and other savings [83]. Another
systematic review concluded that synchronous or real time
video communication was cost-effective for local delivery of
services between hospitals and primary care [84]. Tele-ICU
programs using mobile platforms associated with a rapid
response team delivered care support outside the ICU even
to patients with respiratory distress, reducing avoidable ICU
admissions, without any adverse outcome and resulting in
66% return on investment [85]. Optimal cost-effectiveness
was achieved when tele-ICU was applied to the selected
30–40% highest risk ICU patients [86]. In another study
after hospital discharge, patients with amyotrophic lateral
sclerosis were followed up by phone calls conducted by a
nurse through a clinical card. Over time patients managed
increased by 628%. This system was considered a feasible
tool to manage up to 25 patients per month per nurse:
estimated costs were about 105 Euros ($124) per patient
per month [87]. A pilot tele-medicine program applied to a
wide COPD population resulted in an average 1,089 Euros
($1,280) saving per patient per year [88]. However, to eval-
uate the real cost-effectiveness of any new method of care
such as tele-medicine, the definition of ‘standard therapy’

should be specified in the frame of the different home care
organizations in each country. More cost-effectiveness stu-
dies are needed to provide a definitive answer because
outcome measurements are too dependent on various fac-
tors rather than only technology and organization.
6.2. Reimbursement
Wide adoption of tele-medicine may be hindered by lower
reimbursements as compared with standard services. This may
reduce investments in non-profitable tele-medicine technolo-
gies, even if this modality improves patient outcomes. In the
USA, reimbursements for tele-medicine services were reported
significantly lower than those for standard practice for 7 of the
10 most common services [89]. In a recent survey [90], policies
on tele-medicine were identified in UK, Germany, Italy, and
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Spain. Pilot projects in some chronic diseases including COPD
already existed or were planned. Concerns were expressed
about sharing of medical information and the need for capital
investment. Formal reimbursement was scarce, but more com-
monly available for patients with heart failure [90].
7. Patients’ training
Patients’ age, education, experience in technology, cognitive,
motor, visual, phonation and speech abilities, their families,
and home environment all play an important role in the use of
these technologies. According to a 2010 estimate, most of US
patients suffering from chronic diseases go online including
social media [15]. A recent survey reported that patients
attending a formal pulmonary rehabilitation program includ-
ing maintenance exercise classes and support groups had
high device access and use, and good self-rated technology
competence. Most participants were willing to use tele-reha-
bilitation, especially if they were regular users of technology
devices [91]. Patients and users have to navigate through
several apps connected to wearable devices and determine
by themselves the effectiveness and usefulness of these apps
and devices. They have to pay attention to artifacts due to
calibration problems, temperature, humidity, and motion
[9,92]. Care-givers and patients should be trained in such
technologies and programs in order to enable them to act in
accordance with predefined protocols [93]. Obstacles limiting
the wider diffusion of tele-medicine are shown in Table 2.
8. Conclusions
Information Communication Technology is leading to a care
model centered on use of digital and web-based tools. This
Table 2. Problems to be solved to develop tele-medicine.
● Awareness of patients, stakeholders, professional care-givers
● Uniformity of different systems
● Regulations
● Transparency on data storage and utilization
● Proper reimbursement
● Implementation costs
● Evidence of cost-effectiveness
EXPERT REVIEW OF RESPIRATORY MEDICINE 5
technology might save resources and reduce disparities in deliv-
ery of care. Although tele-medicine systems for management of
patients suffering from chronic respiratory diseases are increas-
ing in number, most have not been validated as clinically effec-
tive. There is a need for widely adopted standards for conducting
trials and reporting results. There is a need for more scientific
evidence, guideline recommendations, and regulatory board
statements before this approach can be considered in the rou-
tine management of patients with respiratory diseases.
9. Expert commentary
Recent advances in information and communication technol-
ogies, in wearable sensors and data transmission, have
allowed for the development of tele-medicine programs for
respiratory diseases as well. Such progress widens horizons in
respiratory medicine: first, tele-medicine can reduce health
care costs moving some interventions from unnecessary cen-
tralized locations to patient’s home; second, it can permit the
delivery of care in countries with limited access to it for
geographical reasons. In the light of the claimed, but not
yet or not always, demonstrated savings associated with this
new trend in medicine, many governments have enthusias-
tically supported research programs in this field, with the aim
to also have a scientific reason to integrate this ‘cheaper’
modality into their health care systems. On their sides, indus-
try has discovered the tele-medicine business and many
academics can hope in new potential developments of their
careers associated with it. These are some of the reasons why
papers published in the field have exponentially increased in
the last years, as the reader can check just looking at the
reference list of this paper. Nevertheless, some caveats must
be considered.
Results of clinical research for some respiratory diseases are
still being discussed if not lacking for others. Positive results
have been reported in systematic reviews and meta-analyses,
but not confirmed in other studies. RCT are difficult to perform
and results often cannot be compared due to, among others,
differences in the pathological, familiar, and environmental
conditions of the individual patient, and in abilities to cope
with technical challenges by patients, relatives, and care-
givers. There are still not enough studies comparing different
wearable sensors and different data transmission techniques.
Results cannot be disseminated and applied without consider-
ing the specifics of each country’s health care organization.
There is a need for widely adopted standards when conduct-
ing trials and reporting results.
In ‘developed’ countries, transferring the burden of care
from consolidated institutions like hospitals with high technol-
ogy and health professionals, to simpler locations like home
environment may not be without risks and should not be
obtained at the expense of care quality and patient’s safety.
On the other hand, in less economically advanced countries
and/or with less sophisticated health systems, tele-medicine
may be a way to fill a void in health care.
More user-friendly, sensible, and precise devices can be
obtained only through fruitful collaboration among medical
doctors, health professionals, bioengineers, and patients,
 6 N. AMBROSINO AND C. FRACCHIA
which is a growing, but not consolidated strategy in all
countries.
Shared solutions to legal issues are still to be defined in
order to protect several stakeholders: the patient’s safety and
privacy first, but also health professionals practice, industry
legitimate interest, and health systems effectiveness.
Last but not least, we need a parallel improvement in
patients’ and health professionals’ awareness of the potential
advantages and limits of this approach.
Despite the hopes in this tool, we need much more evi-
dence before this modality can be considered as a real pro-
gress in the management of patients with respiratory diseases.
On theoretical ground, it is easy to forecast that in the near
future many activities of human health professionals will be
performed by robots or other technologies, and in our cases
by sensors and data transmission systems. Nevertheless, there
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is a role that technology will never be able to play: the
patient–professional relationship and the related necessary
empathy.
10. Five-year view
There is a lot of work to do to meet the expectations raised by
this technology. We need to tailor this tool to the individual
patient, keeping into account age, education, experience in
technology, home environment, cognitive, motor, and visual
abilities. A better definition of the cost-effectiveness ratio may
help decision-makers to integrate this kind of service into
health systems. There is a need for more superiority or at
least non-inferiority RCT, with clear definition of ‘standard
therapy’ as a term of comparison. Many new and unexplored
legal issues must be solved.
Key issues
● Tele-medicine is a clinical application that connects a
patient with specialized care consultants, using an electro-
nic platform.
● This tool might allow for the care of patients with limited
access to health services, and improve their self-
management.
● Wearable sensors and remote health monitoring systems
are available for some respiratory conditions.
● Controlled trials have investigated the feasibility, cost-effec-
tiveness, security, and perspectives of tele-medicine; never-
theless, current literature is inconclusive on the real clinical
benefits.
● The legal problems are still to be solved. Regulators must
indicate ethical, legal, regulatory, technical, and administra-
tive standards.
● The economic advantages should be compared to different
‘gold standards’ of home care models in different countries.
● Much more research is needed before considering tele-
medicine a standard management of these patients.
Funding
This article has not received any funding.
Declaration of interest
The authors have no relevant affiliations or financial involvements with
any organization or entity with a financial interest in or a financial conflict
with the subject matter or material discussed in the article. This includes
employments, consultancies, honoraria, stock ownership or options,
expert testimony, grants, patent, received or pending, or royalties.
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