**1. Introduction**

Chronic obstructive pulmonary diseases (COPD), asthma and lung transplantation have been, by far, the respiratory diseases or conditions more studied, in terms of telemedicine. Howev‐ er, the interest of telehealth providers in new areas also related to neurologic conditions, such as neuromuscular diseases in need of home noninvasive ventilation (NIV) due to chronic respiratory failure, or sleep-related breathing disorders, has arisen in recent years.

Existing evidence reveals promising results regarding reliability and validity of measures across all pulmonary conditions, and patients usually show a positive attitude toward telecare technologies. Other positive effects, for instance, detection of complications, better disease

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

control, immediate feedback, and adequate medication use, have also been addressed [1]. Yet, there is still somewhat decreased adherence within time, possibly secondary to poor health status, time conflicts, device problems, and lack of ability to operate the system [2]. Further‐ more, there is no solid evidence about the utilization of healthcare resources, as well as costeffectiveness, paramount scenarios to advocate in favor of this new way of approaching chronic respiratory patients.

In the following section, current evidence apropos specific respiratory diseases (COPD, asthma, lung transplantation, neuromuscular diseases, and SRBD) will be disclosed, focusing on the positive results, along with the pitfalls found so far.

#### **1.1. Telemedicine**

Telemedicine (TM) has several definitions and all of them emphasize the role of telemedicine to enable the completion of the medical act at distance (**Table 1**) [3–5]. Norrit et al. define TM as a scientific area that uses information and communication technologies (ICT) to share medical information [6]. Thanks to ICT development, TM clinical opportunities are increasing. The information provided by TM programs can be useful for diagnosis and treatment of several diseases, as well as for enhancing their follow-up.


**Table 1.** Telemedicine's definitions.

Historically, Dr. Graham Bell performed the first TM experience, when he used the telephone calling for help when he was sick. Also, in 1923, Sahlgrenska University (Gothenburg) used the Morse code to provide medical advice. TM programs were funded by the privacy industries in 1990 for the first time, and in 1993, the first telemedicine symposium was celebrated. Over 50 years, TM has been used for different programs such as: monitored surgeries, remote assistance in rural zones of Arizona, or vital signs monitoring of astronauts in space, just like

Bashur et al. demonstrated [7]. In fact, aerospace technology development has been one of the most important factors in TM evolution. In 1976, the Hermes satellite was put into orbit with the main objective of improving communications in remote areas of Canada. Since then, the Western Ontario University has been using it for telemonitoring of vital signs, sharing medical information between hospitals and, finally, sharing radiographies [8]. Moreover, the National Aeronautics and Space Administration (NASA) also has used TM to give medical assistance if a disaster takes place.

Generally speaking, TM applications could be classified into three groups: (a) normal clinical activity (teleconsult, telediagnosis, teletreatment, etc.), (b) remote assistance, and (c) adminis‐ tration labors and patient management.

#### *1.1.1. Clinical activity*

control, immediate feedback, and adequate medication use, have also been addressed [1]. Yet, there is still somewhat decreased adherence within time, possibly secondary to poor health status, time conflicts, device problems, and lack of ability to operate the system [2]. Further‐ more, there is no solid evidence about the utilization of healthcare resources, as well as costeffectiveness, paramount scenarios to advocate in favor of this new way of approaching

In the following section, current evidence apropos specific respiratory diseases (COPD, asthma, lung transplantation, neuromuscular diseases, and SRBD) will be disclosed, focusing

Telemedicine (TM) has several definitions and all of them emphasize the role of telemedicine to enable the completion of the medical act at distance (**Table 1**) [3–5]. Norrit et al. define TM as a scientific area that uses information and communication technologies (ICT) to share medical information [6]. Thanks to ICT development, TM clinical opportunities are increasing. The information provided by TM programs can be useful for diagnosis and treatment of several

**WHO** [3] The delivery of health care services, where distance is a critical factor, by all health care

**ATA** [4] Telemedicine is the use of medical information exchanged from one site to another via electronic

**Bashur R**  [5] Telemedicine is conceived of as an integrated system of health-care delivery that employs

advancing the health of individuals and their communities.

and other forms of telecommunications technology.

WHO: World Health Organization; ATA: American Telemedicine Association, Ref: Reference.

professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of

communications to improve a patient's clinical health status. Telemedicine includes a growing variety of applications and services using two-way video, email, smart phones, wireless tools,

telecommunications and computer technology as a substitute for face-to-face contact between

Historically, Dr. Graham Bell performed the first TM experience, when he used the telephone calling for help when he was sick. Also, in 1923, Sahlgrenska University (Gothenburg) used the Morse code to provide medical advice. TM programs were funded by the privacy industries in 1990 for the first time, and in 1993, the first telemedicine symposium was celebrated. Over 50 years, TM has been used for different programs such as: monitored surgeries, remote assistance in rural zones of Arizona, or vital signs monitoring of astronauts in space, just like

chronic respiratory patients.

58 Mobile Health Technologies - Theories and Applications

**1.1. Telemedicine**

on the positive results, along with the pitfalls found so far.

diseases, as well as for enhancing their follow-up.

provider and client.

**Table 1.** Telemedicine's definitions.

**Ref Definition**

Almost all studies are aimed for telemonitoring patients or sharing medical data, where this medical act at distance needs a TM platform and a clinical response. We could classify the clinical response into two groups: synchronic or asynchronic response (**Figure 1**). The main difference is the time to response [9]. While in the first group, the clinical response is immediate and allows performing a live medical act, the second group clinical response is deferred (minutes or few hours). Asynchronic response is useful in telepatologhy or teleradiology, or in other telediagnosis programs.

#### *1.1.2. Remote assistance*

In this group, several medical actions are included such as online records for consulting previous medical charts, establishing a direct communication between patients and physi‐ cians, or teleconference between primary and specialized care doctors, useful for discussing difficult cases and take decisions for complex patients (terminal disease, multiple comorbidi‐ ties, social exclusion, impossibility to attend the hospital, etc.).

#### *1.1.3. Patients' management*

Nowadays, patients manage their medical events via Internet more often, and their doctors can use the same way to give medical recommendations (rehabilitation, nutritional care, tobacco information, or health life recommendations). Obviously, TM is a helpful tool for health care personnel as well. In this case, TM is used to access scientific information or as a type of communication for multicentric and international clinical trials.

#### **1.2. Telemedicine: barriers and benefits**

According to the Europe Institute of Technologies findings, only 14.2% of citizens had used the Internet to solve their health related doubts. The more frequent searches regarding these issues were: disease description, clinical trials, medical literature, or patients' disease associ‐ ations (**Table 2**).


**Table 2.** Search topics by patients and healthcare professionals.

There are several studies that have showed important barriers for applying TM programs. Segrelles-Calvo et al. suggested that healthcare policy, lacking studies about economic burden and cost-effectiveness of TM, no laws regarding the handling of information in TM programs and the resistance to change "usual medicine conception," are some causes that explain slow TM implantation [10]. According to the concept of "resistant to change usual care," Mira-Solves et al. presented the results of the ValCrònic program [11], in which authors discussed the causes to leave a TM program. The main reasons were: (1) difficulty to use the devices, (2) complex measures, (3) nonadherence with TM program, (4) technical problems, and (5) caregivers preferences.

Another important barrier not well studied is the opinion of health professionals toward TM programs. Telemedicine collects a lot of information and their belief is that TM increases workload. However, this belief is not displayed in scientific studies. Jódar-Sánchez et al. [12] showed indeed that a specialized nurse could solve most of the clinical urgencies detected, where only 8 of 40 cases needed a pneumologist intervention. Similar results were published by Vitacca et al. [13] reporting that in 63% of alerts, these could be resolved only by a nurse, and in the rest of them both physician and nurse gave the clinical response. As conclusion, it seems that there are external factors acting as barriers in the TM implantation, and further works are required to establish them. Motulsky et al. [14] and Cresswell et al. [15] pooled those external factors in three groups: (1) healthcare institutions policy, (2) the urge of guidelines about TM, and (3) the need of specific formation and educational resources.

Telemedicine offers four fundamental benefits [4]:


#### **1.3. Telemedicine platforms**

cians, or teleconference between primary and specialized care doctors, useful for discussing difficult cases and take decisions for complex patients (terminal disease, multiple comorbidi‐

Nowadays, patients manage their medical events via Internet more often, and their doctors can use the same way to give medical recommendations (rehabilitation, nutritional care, tobacco information, or health life recommendations). Obviously, TM is a helpful tool for health care personnel as well. In this case, TM is used to access scientific information or as a

According to the Europe Institute of Technologies findings, only 14.2% of citizens had used the Internet to solve their health related doubts. The more frequent searches regarding these issues were: disease description, clinical trials, medical literature, or patients' disease associ‐

There are several studies that have showed important barriers for applying TM programs. Segrelles-Calvo et al. suggested that healthcare policy, lacking studies about economic burden and cost-effectiveness of TM, no laws regarding the handling of information in TM programs and the resistance to change "usual medicine conception," are some causes that explain slow TM implantation [10]. According to the concept of "resistant to change usual care," Mira-Solves et al. presented the results of the ValCrònic program [11], in which authors discussed the causes to leave a TM program. The main reasons were: (1) difficulty to use the devices, (2) complex

ties, social exclusion, impossibility to attend the hospital, etc.).

type of communication for multicentric and international clinical trials.

*1.1.3. Patients' management*

ations (**Table 2**).

**1.2. Telemedicine: barriers and benefits**

60 Mobile Health Technologies - Theories and Applications

**Table 2.** Search topics by patients and healthcare professionals.

In general, there is a common objective in telemedicine programs; however, there are several platforms in which TM could be offered. Telemedicine platforms are related to ICT. The most common scheme in telemedicine (**Figure 2**) is the one that includes devices to measure different vital signs or questionnaires, in order to perform a teleconsultation or to send educational resources to patients. Those measures could be made by the patients, anywhere and anytime. Clinical information is sent to a call center or a health professional by different means (tele‐ phone, Internet, etc.), and the clinical response is made according to all information regarding.

Some of the ICT used in telemedicine platform are as follows:

*Videoconference*. Possibly this ICT was one of the most important technological advances as a telemedicine platform. Mahmud et al. [16] made a follow-up platform of patients with chronic diseases (heart failure, COPD, cerebrovascular disease). In seven cases, the number of emer‐ gency department visits and hospitalizations were reduced, and the authors did not found complications in the use of the videoconference platform. These results were confirmed in 2000 by Johnston et al. [17] and by Nakamura et al. [18]. Johnston determined a reduction of 17% of home visits as well as a 27% reduction of costs in the telemedicine group. Moreover, Nakamura reported an improvement of daily activities in the telemedicine group. Recent studies have used videoconference to improve adherence to a telerehabilitation program [19], to follow-up patients with bipolar disorder [20] or to monitoring tuberculosis therapy com‐ pliance [21], among other topics. According to these studies, in our view the videoconference is a remarkable technology, facilitating the follow-up of patients to improve their adherence to treatment.

**Figure 2.** Telemedicine platform.

*Telephone*. Mainly, studies have focused in the telephone as a device to follow-up of patients but Balas et al. [22] described five possible actions that we could also do via telephone: (1) follow-up, (2) videoconsultation due to interactive telephone, (3) telephonic reminders of taking a medicine or doing an exercise, (4) calling health professionals if case of clinical deterioration, and (5) clinical investigation.

*E-mail*. Email is a rather quick tool for the patients to communicate with health professionals, making it easier for the latter to perform questionnaires so any given doubt of the patient or caregiver could be cleared up.
