The demographic profile and, as a consequence, the health profile of the population are changing Citation[1]. The greatest challenge that we will face over the next 20 years is the management of chronic diseases in aged populations Citation[1], especially in rural areas Citation[2]. The fast epidemiological transition from acute to chronic health problems – from inpatient to outpatient care – presents an urgent need to apply new skills in the healthcare system, together with an increased interest in improving delivery of effective care at home Citation[3]. The patient affected by a chronic disease is a complex subject, characterized by progressive functional decline, difficult individualized prognoses, serious episodes of relapse with, consequently, a high risk of hospitalizations and multiple comorbidities. He or she is also likely to be a heavy burden on the family and/or carer Citation[4,5].
To meet chronic needs, different forms of ‘integrated care’ exist: self-management, education, rehabilitation, general practitioners’ involvement, episodic home nursing visits, and dedicated office and structured home-care programs. All of these are pieces of the complex ‘puzzle’ that is the management of chronic diseases. Chronic disease management must guarantee individualized programs focused on the patient. Indeed, chronic disease management must use a multidisciplinary, integrated and coordinated approach between both clinicians and patients, allowing a smooth transition after the hospital discharge and a continuum of care with respect to the patient and their family.
What is telehealthcare?
Recent advances in information and communication technology, reaching patients at home through telehealthcare (THC) interventions, are considered a helpful way of delivering care to chronic patients in different disease areas Citation[6,7]. THC refers to personalized patient care by electronic transfer of data and biological signals, which involves doctors, specialists and nurses either by phone or video-linkage use. Telemedicine (TM) or teleassistance (TA) is a branch of THC that works as synchronous (real-time) or asynchronous (store and forward) consultation in the form of telemonitoring, telesupport and triaging medical information to the right person at the right time Citation[8].
The TA patient-centered approach needs to introduce the specialized figure of the nurse, whose attitude is critical in the modeling of the new way of working. The role of the nurse as case manager for home assistance in chronic diseases is well accepted and in our experience his/her activity management has progressively increased over time by reducing the family’s burden, reinforcing educational programs and lowering the time doctors spent with patients, reflecting the important shift from a clinician-centered to a nurse-centered program Citation[9].
Weighing the balance between benefits & barriers
Teleassistance offers both opportunities and obstacles Citation[8]. Potential opportunities associated with TM interventions include a new regionalization potential and a linkage between rural districts and hospitals, supporting patients in their preferred location (at home); a greater continuity of care through the use of human resources and technology with quick transmission of information and clinical data in real time; replacement of routine visits; use of telemonitoring of respiratory measures (peak expiratory flow, pulsoximetry, spirometry and ventilator tracings) for an earlier detection of symptom exacerbation; and active education and support. As a consequence, the use of such technologies can involve costly reorganization of the service, mainly related to the need for staff training and of the development of new care pathways. When considering the obstacles of THC initiatives, the most important is a governmental health service that might consider this new healthcare approach as incurring potential administrative difficulties. Moreover, politicians and bureaucrats may have a lack of understanding of what works and what doesn’t work in this field and might obstruct further e-health progress Citation[8]. There are also some concerns on the use of this technology with older people, mainly related to security aspects and confidentiality (i.e., use of passwords required by the system). Moreover, common standards of communication between different systems produced by different companies are lacking and the need for inter-operability remains a goal to be reached. Thus, the set up of a THC system and investment in the technology must be justified by a balance between benefits and barriers Citation[8]. Considerations of such fundamental questions clearly need to be performed before rushing into investment in heavily-marketed TM solutions.
Up until now, potential applications of TM in respiratory disease include home-based clinical diagnosis as well as monitoring and data interpretation at specialized centers. The most extensive experience is in asthma Citation[10], chronic respiratory insufficiency Citation[11,12], use of mechanical ventilation Citation[12] and in the early detection of chronic obstructive pulmonary disease exacerbations Citation[12–14]. The latter has particular appeal due to severe implications of chronic obstructive pulmonary disease exacerbations on the decline of pulmonary function and quality of life. Further areas such as cystic fibrosis, obstructive sleep apnea, neuromuscular diseases and amyotrophic lateral sclerosis, second opinion consultation from general practitioners and acute respiratory failure during epilexia are focusing interest on the use of the TA approach.
Results from meta-analyses published in the last 5 years Citation[13,14] show encouraging results on reduction of the number of hospitalizations and emergency room admissions. However, the major criticism of the interpretation of these studies is due to different experiences on a very low number of patients, the use of different methodologies (phone alone, videoconference and combined systems), different levels of severity of the disease, settings, rationale and resources. For these reasons, despite interesting possibilities having been shown, the results in this field are sometimes weak. Education and skills of the clinical staff, technologies and instrumentation, indicators of outcomes, related legal problems and costs remain further areas to be improved and detailed.
Questions for the future
The discipline of TM is still relatively new and more clarifications and outcomes are needed. Confusion about the terms used to define what TA is and the lack of common standards are two major points that can be better approached through the following questions:
• What is a more appropriate word for describing TM/TA?
• How have we had to consider TM/TA?
• Is TM/TA a complementary system able to integrate health services, a synergic model or an alternative one?
In chronic diseases of high social impact or in elderly patients, or in patients with multiple diseases, other questions are still open:
• What are the pathologies to be managed by TM/TA?
• What are the severity criteria for patient inclusion?
• At what point can the natural history of a patient be managed by TM/TA?
• What about the duration of the disease (and expectation of life), the involvement of staff in terms of workload, and costs and cost–effectiveness for the management of the disease?
Conclusion
We would like this article to promote a new way of thinking about TA, for example, as a ‘virtual hospital’, with several care levels involving a variety of staff and technological tasks, which by directing treatment and support to patients who really need it, reduces the unnecessary use of such resources on patients who do not. TA should be considered as the arms of a network that systematically uses technology and resources in an intelligent, individualized and speedy manner in order to enhance communication among sick patients, staff and the different operators involved in providing healthcare.
Clear thinking and sound research will be needed to free us from the stalemate that often exists between healthcare staff and politicians who enthusiastically welcome both new technologies in general and TM in particular, and healthcare staff and politicians who maintain skepticism towards innovation.
Acknowledgements
The authors thank Patrick Hodgkins for the English revision of the manuscript.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
References
- Young HM. Challenges and solutions for care of frail older adults. World Health Organization Global Observatory for eHealth. Global eHealth Survey Geneva July 2005. Online J. Issues Nurs.8(2), 5 (2003).
- Rygh EM, Hjortdahl P. Continuous and integrated health care services in rural areas. A literature study. Rural Remote Health7(3), 766 (2007).
- American Thoracic Society. Statement on home care for patients with respiratory disorders. Am. J. Respir. Crit. Care Med.171, 1443–1464 (2005).
- Curtis JR. Palliative and end-of-life care for patients with severe COPD. Eur. Respir. J.32(3), 796–803 (2008).
- Vitacca M, Escarrabill J, Galavotti G et al. Home mechanical ventilation patients: a retrospective survey to identify level of burden in real life. Monaldi Arch. Chest Dis.67(3), 142–147 (2007).
- Clark RA, Inglis SC, McAlister FA, Cleland JG, Stewart S. Telemonitoring or structured telephone support programmes for patients with chronic heart failure: systematic review and meta-analysis. Br. Med. J.334(7600), 942 (2007).
- Hersh WR, Hickam DH, Severance SM, Dana TL, Krages KP, Helfand M. Telemedicine for the medicare population: update. Evid. Rep. Technol. Assess.131, 1–41 (2006).
- Vitacca M, Mazzù M, Scalvini S. Socio–technical and organisational challenges to wide e-health implementation. Chronic Respiratory Disease6, 91–97 (2009).
- Vitacca M, Bazza A, Bianchi L et al. Tele-assistance in chronic respiratory failure: patients’ characterization and staff workload of 5-year activity. Telemed. J. E. Health.16(3), 299–305 (2009).
- Finkelstein J, O’Connor G, Friedmann RH. Development and implementation of the home asthma telemonitoring (HAT) system to facilitate asthma self-care. Stud. Health Technol. Inform.84(Pt 1), 810–814 (2001).
- Maiolo C, Mohamed EI, Fiorani CM, De Lorenzo A. Home tele-monitoring for patients with severe respiratory illnesses: the Italian experience. J. Telemed. Telecare9, 67–71 (2003).
- Vitacca M, Bianchi L, Guerra A et al. Tele-assistance in chronic respiratory failure patients: a randomised clinical trial. Eur. Respir. J.33(2), 411–418 (2009).
- Jaana M, Paré G, Sicotte C. Home telemonitoring for respiratory conditions: a systematic review. Am. J. Manag. Care.15(5), 313–320 (2009).
- Polisena J, Tran K, Cimon K et al. Home telehealth for chronic obstructive pulmonary disease: a systematic review and meta-analysis. J. Telemed. Telecare16(3), 120–127 (2010).