ABSTRACT

OBJECTIVE

Mapping the role of telemedicine in the health access of patients with chronic diseases in continuous care actions (except for covid-19) during the pandemic.

METHODS

This is a scoping review, with an adapted version of the Prisma-Scr methodology and using the Population (patients with chronic diseases), Concept (telemedicine as a health access tool) and Context (covid-19 pandemic) strategy. We searched through the following databases: PubMed, Scopus, Embase, Web of Science, Lilacs and SciELO, resulting in 18 articles at the end of the review. We used the technological, sociocultural and assistance analysis dimensions.

RESULTS

Eighty-eight percent of the analyzed papers posited that telemedicine use to provide care increased during the pandemic. We identified that this use was positively related to the reduction of complications and the absence of physical displacement for care, expanding it to rural areas. Important barriers were presented, most importantly the digital exclusion, language sociocultural barriers, and inaccessibility to technological instruments for disabled people.

CONCLUSIONS

Innovation in care arrangements calls attention to how living labor is important to produce healthcare, using various technologies, and reveals tensions caused by the forces acting on healthcare micro politics. We conclude that, despite important barriers, telemedicine contributed to the care of chronic patients during the covid-19 pandemic.

COVID-19; Telemedicine; Telemedicine Emergency Care; Continuity of Patient Care; Health Services Accessibility

INTRODUCTION

The organization and preparation of international health systems changed after the declaration of the Public Health Emergency of International Concern (PHEIC) issued by the World Health Organization (WHO) in January, 2020, due to the global outbreak of coronavirus¹1. World Health Organization. WHO Director-General’s opening remarks at the media briefing on COVID-19 - 11 March 2020 [cited 2022 Jan 10]. Available from: https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020
https://www.who.int/director-general/spe... . Recommendations included supporting fragile health systems, developing immunizers, as well as therapeutic strategies, combating misinformation, strengthening diagnostic mechanisms with an emphasis nor only on isolation, but also transmission prevention, and stimulating the sharing of scientific knowledge and international cooperation.

The first months of viral contamination posed enormous challenges to treating infected patients, overstretching health systems and demanding health services, such as hospitals and outpatient clinics, to change their routine immediately. The concentration of efforts in treating cases of severe acute respiratory syndrome (SARS) caused postponements and cancellation of face-to-face health actions to protect patients from exposure to the virus²2. Tasca R, Massuda A. Estratégias para reorganização da Rede de Atenção à Saúde em resposta à Pandemia COVID-19: a experiência do Sistema de Saúde Italiano na região de Lazio. APS Rev. 2020;2(1):20-7. https://doi.org/10.14295/aps.v2i1.65
https://doi.org/10.14295/aps.v2i1.65... .

The high case incidence during the pandemic created new strains of SARS-CoV-2, collapsing many health systems, which made it urgent to resume the care of non-covid patients and the chronically ill, offering continuous care⁶6. Macinko J, Woolley NO, Seixas BV, Andrade, FB, Lima-Costa MF. Health care seeking due to COVID-19 related symptoms and health care cancellations among older Brazilian adults: the ELSI-COVID-19 initiative. Cad Saúde Pública. 2020;36(suppl 3):e00181920. https://doi.org/10.1590/0102-311x00181920
https://doi.org/10.1590/0102-311x0018192... ,⁷7. John N, Wang GM, Cioffi G, Waite K, Patil N, Kyasaram R, et al. The negative impact of the COVID-19 pandemic on oncology care at an Academic Cancer Referral Center. Oncology (Williston Park). 2021 Aug;35(8):462-70. https://doi.org/10.46883/ONC.2021.3508.0462
https://doi.org/10.46883/ONC.2021.3508.0... ;. The need to reorganize services, tasks and reinvent ways of doing health was strongly evidenced and considered fundamental⁸8. Stralen AC, Carvalho CL, Girardi SN, Massote AW, Cherchiglia ML. Estratégias internacionais de flexibilização da regulação da prática de profissionais de saúde em resposta à pandemia da COVID-19: revisão de escopo. Cad Saúde Pública. 2022;38(2):e00116321. https://doi.org/10.1590/0102-311x00116321
https://doi.org/10.1590/0102-311x0011632... . Thus, the technology use gained global prominence in health actions, work and educational activities, as well as to financial and commercial transactions²2. Tasca R, Massuda A. Estratégias para reorganização da Rede de Atenção à Saúde em resposta à Pandemia COVID-19: a experiência do Sistema de Saúde Italiano na região de Lazio. APS Rev. 2020;2(1):20-7. https://doi.org/10.14295/aps.v2i1.65
https://doi.org/10.14295/aps.v2i1.65... .

The first pandemic confronting reports indicate the monitoring of suspected and confirmed cases by phone or smartphone application, as well as the deployment of telemedicine tools²2. Tasca R, Massuda A. Estratégias para reorganização da Rede de Atenção à Saúde em resposta à Pandemia COVID-19: a experiência do Sistema de Saúde Italiano na região de Lazio. APS Rev. 2020;2(1):20-7. https://doi.org/10.14295/aps.v2i1.65
https://doi.org/10.14295/aps.v2i1.65... to guide the general population. These tools served as an initial screening to measure the severity of cases, helping to guide the users’ search for health services, with the objective of prioritizing demand. Countries such as France and the United Kingdom implemented telemedicine actions early, ensuring the compensation of the procedures through the National Health Insurance⁹9. Chamboredon P, Roman C, Colson S. COVID-19 pandemic in France: health emergency experiences from the field. Int Nurs Rev. 2020 Sep;67(3):326-33. https://doi.org/10.1111/inr.12604
https://doi.org/10.1111/inr.12604... and using voice and video resources that also increased the self-care of patients with respiratory diseases¹⁰10. Carroll WD, Strenger V, Eber E, Porcaro F, Cutrera R, Fitzgerald DA, et al. European and United Kingdom COVID-19 pandemic experience: the same but different. Paediatr Respir Rev. 2020 Sep;35:50-6. https://doi.org/10.1016/j.prrv.2020.06.012
https://doi.org/10.1016/j.prrv.2020.06.0... .

Even before the emergence of the new coronavirus, several factors contributed to the growth of telemedicine, such as technological advances in communication and information. This a result of the increasing use of high-speed internet and the rise in the number of files in electronic medical records in health services¹¹11. Eze ND, Mateus C, Hashiguchi TCOI. Telemedicine in the OECD: an umbrella review of clinical and cost-effectiveness, patient experience and implementation. PLoS One. 2020 Aug;15(8):e0237585. https://doi.org/10.1371/journal.pone.0237585
https://doi.org/10.1371/journal.pone.023... . For Cordioli¹²12. Cordioli E. Telemedicina nas especialidades: da teoria à prática. In: Santos AO, Lopes LT, editores. Acesso e cuidado especializados. Brasília, DF: Conselho Nacional de Secretários de Saúde; 2021. p. 136-47., telemedicine comprises the service provision related to healthcare in cases where distance is a critical factor, and can be used both for urgent consultations, in the context of covid-19, and routine appointments, given the need of overcoming access barriers, ensuring data protection and providing alternatives to physical examination.

In this context, telemedicine (or telehealth) has different applications, such as teleconsultation, telemonitoring, teleregulation, teleorientation, among others¹³13. Caetano R, Silva AB, Guedes AC, Paiva CC, Ribeiro GD, Santos DL, et al. Desafios e oportunidades para telessaúde em tempos da pandemia pela COVID-19: uma reflexão sobre os espaços e iniciativas no contexto brasileiro. Cad Saúde Pública. 2020;36(5):e00088920. https://doi.org/10.1590/0102-311x00088920
https://doi.org/10.1590/0102-311x0008892... . Currently, the term telemedicine is associated with the terms telehealth and e-Health, with imprecise conceptual distinctions¹⁴14. Maldonado JM, Marques AB, Cruz A. Telemedicina: desafios à sua difusão no Brasil. Cad Saúde Pública. 32(suppl 2): e00155615. https://doi.org/10.1590/0102-311X00155615
https://doi.org/10.1590/0102-311X0015561... . During the expanded literature search, it was possible to distinguish the use of telemedicine in two large groups: the use of technology as a care arrangement for infected patients and the use of technology as a care arrangement for non-covid patients, a possibility for which this study is interested, regarding access and continuity of care.

This scoping review aims at mapping the contribution of telemedicine to health access of patients with chronic diseases in continuous care actions – non-covid – in the context of the pandemic. The chosen methodology makes it possible to identify the existing literature on the subject, providing elements to analyze the use of telemedicine in the context of covid-19, recognize innovations and new care arrangements, and locate barriers to health access. The analysis of healthcare produced during the pandemic, in the different dimensions, can help us elaborate more balanced public policies and build resilient health systems, with immediate emergency response, and also improve healthcare of chronic patients¹⁵15. Tanaka OY. Avaliação no contemporâneo: dilemas e desafios. Rev Bras Aval. 2021;10(1):e100721. https://doi.org/10.4322/rbaval202110007
https://doi.org/10.4322/rbaval202110007... .

METHODS

This is a scoping review, which is a literature review modality that has been widely used in mapping the existing literature on a given topic, allowing us to recognize and clarify definitions and conceptual limits¹⁶16. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19-32. https://doi.org/10.1080/1364557032000119616
https://doi.org/10.1080/1364557032000119... ,¹⁷17. Peters MD, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid-Based Healthc. 2015 Sep;13(3):141-6. https://doi.org/10.1097/XEB.0000000000000050
https://doi.org/10.1097/XEB.000000000000... . In order to do so, we used an adapted version of the Prisma-scr manual¹⁸18. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018 Oct;169(7):467-73. https://doi.org/10.7326/M18-0850
https://doi.org/10.7326/M18-0850... , which clusters 22 verification steps concerning the title, abstract, introduction, method and discussion.

We initially used the population, concept and context (PCC) strategy to direct and define the scope of the study, with P (population) = patients with chronic diseases, C (concept) = telemedicine as a tool for access to health and C (context) = covid-19 pandemic. Using the PCC allowed us to formulate our research question “did telemedicine contribute to access to health services for patients with chronic diseases during the covid-19 pandemic?”. This question directed the searches for scientific papers indexed in PubMed, Scopus, Embase, Web of Science, Lilacs and SciELO, selected from the Academic Information Agency of the Universidade de São Paulo with the indexing criterion defined for journals in Public Health¹⁹19. Universidade de São Paulo. Agência de Bibliotecas e Coleções Digitais. Base de dados. [cited 2022 Mar 23]. Available from: https://www.aguia.usp.br/Bases-Dados/
https://www.aguia.usp.br/Bases-Dados/... . The searches in the databases were carried out between January and March, 2022.

The search of scientific papers which integrated the review occurred from the search command-line built with the Health Science Descriptors - DeCs (Telemedicine AND Chronic Diseases AND COVID-19 AND Access to health care), including the period from March, 2020 to March, 2022 for publications in English, followed by double-blind evaluation for the scope assessment stages. All types of scientific papers were included, as well as scientific reviews, without geographical limitation and regardless of publication type. Regarding the results shown in Figure 1, title and keywords were considered in the first analysis and initially included n = 342 papers, 32.16% of which were from PubMed, which retrieved the highest number of results, followed by Web of Science (24.26%) and Scopus (23.39%). The papers were saved in the reference management software Endnote and processed by the platform Rayyan.

In these results, the following exclusion criteria were applied: articles which did not address the use of telemedicine, directed to populations that were not formed by chronic patients, outside the covid-19 pandemic period, discussing specialties that do not fit the chronic criterion and addressing issues related to mental health (n = 98 papers). In the Rayyan platform, duplicates were removed (n = 80 papers) and articles from additional sources were inserted (n = 2 papers), in addition to performing a second double-blind evaluation of the previous results, considering title and abstract (n = 166 papers). At this stage, the inclusion conflicts (n = 11 papers) were sent to new reviewers in double-blind evaluation for final decision, in which n = 5 papers were included.

The analysis included n = 49 papers for full content evaluation; from which, only n = 18 papers were selected for the scope study, because they present elements that can help us answer the research question. We analyzed the following dimensions: technological (type of technology used, resources used, identified innovations), sociocultural (age, income, language) and assistance (type of chronic disease, professionals involved in care, technical and ethical limitations). After extracting the results, they were categorized and discussed by the authors.

RESULTS

The results identified in the scope of the 18 selected articles are presented in the Chart, containing the characterization of the studies (place of study, publication year, authors, language, description of the study, type of chronic disease studied and type of digital health care technology used). The identified conclusions are presented in Figure 2, an Analytical Diagram including aspects of the analysis carried out by the authors, which will be presented in the discussion.

All papers were published in English, but differed in geographical distribution: n = 10 of the papers were produced in the United States²⁰20. Albert SL, Paul MM, Nguyen AM, Shelley DR, Berry CA. A qualitative study of high-performing primary care practices during the COVID-19 pandemic. BMC Fam Pract. 2021 Nov;22(1):237. https://doi.org/10.1186/s12875-021-01589-4
https://doi.org/10.1186/s12875-021-01589... and n = 1 was a study performed in Latin America³⁰30. Kruse MH, Durstine A, Evans DP. (2021). Effect of COVID-19 on patient access to healthservices in Latin America: a key informant survey. Int J Equity Health (Preprint), 2021 [cited ano mês dia], Available from: https://doi.org/10.21203/rs.3.rs-738539/v1
https://doi.org/10.21203/rs.3.rs-738539/... . Southeast Asia, on the other hand, was cited in n = 1 paper³¹31. Gudi N, Konapur R, John O, Sarbadhikari S, Landry M. Telemedicine supported strengthening of primary care in WHO South East Asia region: lessons from the COVID-19 pandemic experiences. BMJ Innov. 2021;7(3):580-5. https://doi.org/10.1136/bmjinnov-2021-000699
https://doi.org/10.1136/bmjinnov-2021-00... , and Italy³²32. Volpato E, Centanni S, Banfi P, D’Antonio S, Peterle E, Bugliaro F, et al. Narrative analysis of the impact of COVID-19 on patients with chronic obstructive pulmonary disease, their caregivers, and healthcare professionals in Italy. Int J Chron Obstruct Pulmon Dis. 2021 Jul;16:2181-201. https://doi.org/10.2147/COPD.S312372
https://doi.org/10.2147/COPD.S312372... , the United Kingdom³³33. Lewis A, Knight E, Bland M, Middleton J, Mitchell E, McCrum K, et al. Feasibility of an online platform delivery of pulmonary rehabilitation for individuals with chronic respiratory disease. BMJ Open Respir Res. 2021 Mar;8(1):e000880. https://doi.org/10.1136/bmjresp-2021-000880
https://doi.org/10.1136/bmjresp-2021-000... , Germany³⁴34. Kayser MZ, Valtin C, Greer M, Karow B, Fuge J, Gottlieb J. Video consultation during the COVID-19 pandemic: a single center’s experience with lung transplant recipients. Telemed J E Health. 2021 Jul;27(7):807-15. https://doi.org/10.1089/tmj.2020.0170
https://doi.org/10.1089/tmj.2020.0170... , Canada³⁵35. Wickerson L, Helm D, Gottesman C, Rozenberg D, Singer LG, Keshavjee S, et al. Telerehabilitation for lung transplant candidates and recipients during the COVID-19 pandemic: program evaluation. JMIR Mhealth Uhealth. 2021 Jun;9(6):e28708. https://doi.org/10.2196/28708
https://doi.org/10.2196/28708... and Turkey³⁶36. Alvarez-Risco A, Del-Aguila-Arcentales S, Yáñez JA. Telemedicine in Peru as a result of the COVID-19 pandemic: perspective from a country with limited internet access. Am J Trop Med Hyg. 2021 May;105(1):6-11. https://doi.org/10.4269/ajtmh.21-0255
https://doi.org/10.4269/ajtmh.21-0255... also contributed with n = 1 paper each. We identified only one study with a systematic review methodology, which mentioned having considered studies from five regions of the World Health Organization (WHO), with a predominance of articles from Europe³⁷37. Deng D, Liang A, Chui JN, Wong G, Cooper TE. The COVID-19 pandemic and access to health care in people with chronic kidney disease: A systematic review and meta-analysis. Nephrology (Carlton). 2022 May;27(5):410-20. https://doi.org/10.1111/nep.14016; Online ahead of print
https://doi.org/10.1111/nep.14016... .

As for the publication date of the studies, 77% of them were published in 2021, while 16% correspond to the first year of the covid-19 pandemic. In addition, only n = 1 paper was published more recently, in 2022. Regarding the type of study and data source, 44% of the studies are quantitative, with primary data sources and collected through questionnaires applied by telephone or via the internet. Only n = 4 studies used qualitative methods, and n = 2 papers presented narratives as data source; besides, there were systematic reviews, evaluation and mixed methods papers, each of them corresponding to 11% of the total.

Concerning the type of digital health care technology used, 44% of the studies referred to the use of telemedicine²¹21. Boyce DM, Thomashow BM, Sullivan J, Tal-Singer R. New adopters of telemedicine during the Coronavirus-19 pandemic in respondents to an online community survey: the case for access to remote management tools for individuals with chronic obstructive pulmonary disease. Chronic Obstr Pulm Dis (Miami). 2021 Apr;8(2):213-8. https://doi.org/10.15326/jcopdf.2020.0181
https://doi.org/10.15326/jcopdf.2020.018... . Telehealth was cited in 27% of the analyzed articles ²⁰20. Albert SL, Paul MM, Nguyen AM, Shelley DR, Berry CA. A qualitative study of high-performing primary care practices during the COVID-19 pandemic. BMC Fam Pract. 2021 Nov;22(1):237. https://doi.org/10.1186/s12875-021-01589-4
https://doi.org/10.1186/s12875-021-01589... ,²⁷27. Uscher-Pines L, Thompson J, Taylor P, Dean K, Yuan T, Tong I, et al. Where virtual care was already a reality: experiences of a nationwide telehealth service provider during the COVID-19 pandemic. J Med Internet Res. 2020 Dec;22(12):e22727. https://doi.org/10.2196/22727
https://doi.org/10.2196/22727... , telerehabilitation in 11%²⁵25. Solomon GM, Bailey J, Lawlor J, Scalia P, Sawicki GS, Dowd C, et al. Patient and family experience of telehealth care delivery as part of the CF chronic care model early in the COVID-19 pandemic. J Cyst Fibros. 2021 Dec;20 Suppl 3:41-6. https://doi.org/10.1016/j.jcf.2021.09.005
https://doi.org/10.1016/j.jcf.2021.09.00... ,³²32. Volpato E, Centanni S, Banfi P, D’Antonio S, Peterle E, Bugliaro F, et al. Narrative analysis of the impact of COVID-19 on patients with chronic obstructive pulmonary disease, their caregivers, and healthcare professionals in Italy. Int J Chron Obstruct Pulmon Dis. 2021 Jul;16:2181-201. https://doi.org/10.2147/COPD.S312372
https://doi.org/10.2147/COPD.S312372... and teleneurology²⁴24. McGinley MP, Ontaneda D, Wang Z, Weber M, Shook S, Stanton M, et al. Teleneurology as a solution for outpatient care during the COVID-19 pandemic. Telemed J E Health. 2020 Dec;26(12):1537-9. https://doi.org/10.1089/tmj.2020.0137
https://doi.org/10.1089/tmj.2020.0137... , video consultation³⁴34. Kayser MZ, Valtin C, Greer M, Karow B, Fuge J, Gottlieb J. Video consultation during the COVID-19 pandemic: a single center’s experience with lung transplant recipients. Telemed J E Health. 2021 Jul;27(7):807-15. https://doi.org/10.1089/tmj.2020.0170
https://doi.org/10.1089/tmj.2020.0170... and remote monitoring³⁵35. Wickerson L, Helm D, Gottesman C, Rozenberg D, Singer LG, Keshavjee S, et al. Telerehabilitation for lung transplant candidates and recipients during the COVID-19 pandemic: program evaluation. JMIR Mhealth Uhealth. 2021 Jun;9(6):e28708. https://doi.org/10.2196/28708
https://doi.org/10.2196/28708... accounted for 15% of the total. It bears noticing that we mainly considered the technology cited in the study, since some authors used more than one technology.

Chronic respiratory diseases represented 50% of the articles, being the disease group that relied the most on telemedicine, especially chronic obstructive pulmonary disease (COPD) (n = 4 papers) and cystic fibrosis (n = 2 papers). Only 22% of the articles did not delimit the type of chronic disease, characterizing them as chronic diseases in general. We also included studies on diabetes, cancer and chronic neurological diseases, which corresponded to 15% of the total. Half of the identified articles presented the increased use of telemedicine for the care of patients with chronic diseases during the covid-19 pandemic as the main result²⁰20. Albert SL, Paul MM, Nguyen AM, Shelley DR, Berry CA. A qualitative study of high-performing primary care practices during the COVID-19 pandemic. BMC Fam Pract. 2021 Nov;22(1):237. https://doi.org/10.1186/s12875-021-01589-4
https://doi.org/10.1186/s12875-021-01589... ,²³23. Ladin K, Porteny T, Perugini JM, Gonzales KM, Aufort KE, Levine SK, et al. Perceptions of telehealth vs in-person visits among older adults with advanced kidney disease, care partners, and clinicians. JAMA Netw Open. 2021 Dec;4(12):e2137193. https://doi.org/10.1001/jamanetworkopen.2021.37193
https://doi.org/10.1001/jamanetworkopen.... .

The beginning of telemedicine activities was also reported In n = 3 papers²¹21. Boyce DM, Thomashow BM, Sullivan J, Tal-Singer R. New adopters of telemedicine during the Coronavirus-19 pandemic in respondents to an online community survey: the case for access to remote management tools for individuals with chronic obstructive pulmonary disease. Chronic Obstr Pulm Dis (Miami). 2021 Apr;8(2):213-8. https://doi.org/10.15326/jcopdf.2020.0181
https://doi.org/10.15326/jcopdf.2020.018... ,²⁶26. Tsutsui M, Gerayeli F, Sin DD. Pulmonary rehabilitation in a Post-COVID-19 world: telerehabilitation as a new standard in patients with COPD. Int J Chron Obstruct Pulmon Dis. 2021 Feb;16:379-91. https://doi.org/10.2147/COPD.S263031
https://doi.org/10.2147/COPD.S263031... ,³⁷37. Deng D, Liang A, Chui JN, Wong G, Cooper TE. The COVID-19 pandemic and access to health care in people with chronic kidney disease: A systematic review and meta-analysis. Nephrology (Carlton). 2022 May;27(5):410-20. https://doi.org/10.1111/nep.14016; Online ahead of print
https://doi.org/10.1111/nep.14016... . We identified other results related to the use of telemedicine in the healthcare of chronic patients, such as the improvement of indicators³³33. Lewis A, Knight E, Bland M, Middleton J, Mitchell E, McCrum K, et al. Feasibility of an online platform delivery of pulmonary rehabilitation for individuals with chronic respiratory disease. BMJ Open Respir Res. 2021 Mar;8(1):e000880. https://doi.org/10.1136/bmjresp-2021-000880
https://doi.org/10.1136/bmjresp-2021-000... decrease in complications³⁶36. Alvarez-Risco A, Del-Aguila-Arcentales S, Yáñez JA. Telemedicine in Peru as a result of the COVID-19 pandemic: perspective from a country with limited internet access. Am J Trop Med Hyg. 2021 May;105(1):6-11. https://doi.org/10.4269/ajtmh.21-0255
https://doi.org/10.4269/ajtmh.21-0255... , increased patient receptivity²⁹29. Turner K, Bobonis Babilonia M, Naso C, Nguyen O, Gonzalez BD, Oswald LB, et al. Health care providers’ and professionals’ experiences with telehealth oncology implementation during the COVID-19 pandemic: a qualitative study. J Med Internet Res. 2022 Jan;24(1):e29635. https://doi.org/10.2196/29635
https://doi.org/10.2196/29635... , video consultations with concrete clinical recommendations / medicine change³⁴34. Kayser MZ, Valtin C, Greer M, Karow B, Fuge J, Gottlieb J. Video consultation during the COVID-19 pandemic: a single center’s experience with lung transplant recipients. Telemed J E Health. 2021 Jul;27(7):807-15. https://doi.org/10.1089/tmj.2020.0170
https://doi.org/10.1089/tmj.2020.0170... and identification of benefits in pre-and postoperative care³⁵35. Wickerson L, Helm D, Gottesman C, Rozenberg D, Singer LG, Keshavjee S, et al. Telerehabilitation for lung transplant candidates and recipients during the COVID-19 pandemic: program evaluation. JMIR Mhealth Uhealth. 2021 Jun;9(6):e28708. https://doi.org/10.2196/28708
https://doi.org/10.2196/28708... . On the other hand, there were unfavorable results regarding the use of telemedicine, such as the identification of patients’ inability to use²⁶26. Tsutsui M, Gerayeli F, Sin DD. Pulmonary rehabilitation in a Post-COVID-19 world: telerehabilitation as a new standard in patients with COPD. Int J Chron Obstruct Pulmon Dis. 2021 Feb;16:379-91. https://doi.org/10.2147/COPD.S263031
https://doi.org/10.2147/COPD.S263031... , lower patient engagement²⁹29. Turner K, Bobonis Babilonia M, Naso C, Nguyen O, Gonzalez BD, Oswald LB, et al. Health care providers’ and professionals’ experiences with telehealth oncology implementation during the COVID-19 pandemic: a qualitative study. J Med Internet Res. 2022 Jan;24(1):e29635. https://doi.org/10.2196/29635
https://doi.org/10.2196/29635... , problems with emotional responses and approach to complex issues²⁹29. Turner K, Bobonis Babilonia M, Naso C, Nguyen O, Gonzalez BD, Oswald LB, et al. Health care providers’ and professionals’ experiences with telehealth oncology implementation during the COVID-19 pandemic: a qualitative study. J Med Internet Res. 2022 Jan;24(1):e29635. https://doi.org/10.2196/29635
https://doi.org/10.2196/29635... and access difficulty, including to electronically prescribed medicines³⁰30. Kruse MH, Durstine A, Evans DP. (2021). Effect of COVID-19 on patient access to healthservices in Latin America: a key informant survey. Int J Equity Health (Preprint), 2021 [cited ano mês dia], Available from: https://doi.org/10.21203/rs.3.rs-738539/v1
https://doi.org/10.21203/rs.3.rs-738539/... .

The innovations incorporated in the scope of care performed by telemedicine presented structural and assistance characteristics. Among the structural innovations, sending equipment to monitor and measure vital signs (blood pressure measuring device, glucometer, pulse oximeter, home spirometer, among others) to the patients was the most common arrangement, being present in 27% of the studies²⁰20. Albert SL, Paul MM, Nguyen AM, Shelley DR, Berry CA. A qualitative study of high-performing primary care practices during the COVID-19 pandemic. BMC Fam Pract. 2021 Nov;22(1):237. https://doi.org/10.1186/s12875-021-01589-4
https://doi.org/10.1186/s12875-021-01589... ,³¹31. Gudi N, Konapur R, John O, Sarbadhikari S, Landry M. Telemedicine supported strengthening of primary care in WHO South East Asia region: lessons from the COVID-19 pandemic experiences. BMJ Innov. 2021;7(3):580-5. https://doi.org/10.1136/bmjinnov-2021-000699
https://doi.org/10.1136/bmjinnov-2021-00... ,³⁴34. Kayser MZ, Valtin C, Greer M, Karow B, Fuge J, Gottlieb J. Video consultation during the COVID-19 pandemic: a single center’s experience with lung transplant recipients. Telemed J E Health. 2021 Jul;27(7):807-15. https://doi.org/10.1089/tmj.2020.0170
https://doi.org/10.1089/tmj.2020.0170... .

Blood collection at home²⁰20. Albert SL, Paul MM, Nguyen AM, Shelley DR, Berry CA. A qualitative study of high-performing primary care practices during the COVID-19 pandemic. BMC Fam Pract. 2021 Nov;22(1):237. https://doi.org/10.1186/s12875-021-01589-4
https://doi.org/10.1186/s12875-021-01589... , deployment of drive-thru labs¹⁹19. Universidade de São Paulo. Agência de Bibliotecas e Coleções Digitais. Base de dados. [cited 2022 Mar 23]. Available from: https://www.aguia.usp.br/Bases-Dados/
https://www.aguia.usp.br/Bases-Dados/... and the delivery of medicine at home³¹31. Gudi N, Konapur R, John O, Sarbadhikari S, Landry M. Telemedicine supported strengthening of primary care in WHO South East Asia region: lessons from the COVID-19 pandemic experiences. BMJ Innov. 2021;7(3):580-5. https://doi.org/10.1136/bmjinnov-2021-000699
https://doi.org/10.1136/bmjinnov-2021-00... ,³⁶36. Alvarez-Risco A, Del-Aguila-Arcentales S, Yáñez JA. Telemedicine in Peru as a result of the COVID-19 pandemic: perspective from a country with limited internet access. Am J Trop Med Hyg. 2021 May;105(1):6-11. https://doi.org/10.4269/ajtmh.21-0255
https://doi.org/10.4269/ajtmh.21-0255... were also listed. Other structural arrangements are related to the offered technology itself, such as the availability of e-learning platforms to train patients³³33. Lewis A, Knight E, Bland M, Middleton J, Mitchell E, McCrum K, et al. Feasibility of an online platform delivery of pulmonary rehabilitation for individuals with chronic respiratory disease. BMJ Open Respir Res. 2021 Mar;8(1):e000880. https://doi.org/10.1136/bmjresp-2021-000880
https://doi.org/10.1136/bmjresp-2021-000... and the possibility of using multiple platforms²⁴24. McGinley MP, Ontaneda D, Wang Z, Weber M, Shook S, Stanton M, et al. Teleneurology as a solution for outpatient care during the COVID-19 pandemic. Telemed J E Health. 2020 Dec;26(12):1537-9. https://doi.org/10.1089/tmj.2020.0137
https://doi.org/10.1089/tmj.2020.0137... enabling access for those who have less technological aptitude, in addition to partnerships with University Hospitals and medical schools³¹31. Gudi N, Konapur R, John O, Sarbadhikari S, Landry M. Telemedicine supported strengthening of primary care in WHO South East Asia region: lessons from the COVID-19 pandemic experiences. BMJ Innov. 2021;7(3):580-5. https://doi.org/10.1136/bmjinnov-2021-000699
https://doi.org/10.1136/bmjinnov-2021-00... .

The technological arrangements of care identified as assistance are those invented, adapted or used for the care performed by the health professional or the care chain, through digital technologies. In this sense, it is possible to list prescriptions online³⁰30. Kruse MH, Durstine A, Evans DP. (2021). Effect of COVID-19 on patient access to healthservices in Latin America: a key informant survey. Int J Equity Health (Preprint), 2021 [cited ano mês dia], Available from: https://doi.org/10.21203/rs.3.rs-738539/v1
https://doi.org/10.21203/rs.3.rs-738539/... ,³¹31. Gudi N, Konapur R, John O, Sarbadhikari S, Landry M. Telemedicine supported strengthening of primary care in WHO South East Asia region: lessons from the COVID-19 pandemic experiences. BMJ Innov. 2021;7(3):580-5. https://doi.org/10.1136/bmjinnov-2021-000699
https://doi.org/10.1136/bmjinnov-2021-00... ,³⁶36. Alvarez-Risco A, Del-Aguila-Arcentales S, Yáñez JA. Telemedicine in Peru as a result of the COVID-19 pandemic: perspective from a country with limited internet access. Am J Trop Med Hyg. 2021 May;105(1):6-11. https://doi.org/10.4269/ajtmh.21-0255
https://doi.org/10.4269/ajtmh.21-0255... , use telemedicine for comprehensive patient care²⁸28. Womack C, Farsin R, Farsad M, Chaudary N. Emerging alternatives to conventional clinic visits in the era of COVID-19: adoption of telehealth at VCU Adult Cystic Fibrosis Center. Int J Gen Med. 2020 Nov;13:1175-86. https://doi.org/10.2147/IJGM.S274193
https://doi.org/10.2147/IJGM.S274193... , including pre-and postoperative care³⁷37. Deng D, Liang A, Chui JN, Wong G, Cooper TE. The COVID-19 pandemic and access to health care in people with chronic kidney disease: A systematic review and meta-analysis. Nephrology (Carlton). 2022 May;27(5):410-20. https://doi.org/10.1111/nep.14016; Online ahead of print
https://doi.org/10.1111/nep.14016... , acting in the regulation and management of complex cases³¹31. Gudi N, Konapur R, John O, Sarbadhikari S, Landry M. Telemedicine supported strengthening of primary care in WHO South East Asia region: lessons from the COVID-19 pandemic experiences. BMJ Innov. 2021;7(3):580-5. https://doi.org/10.1136/bmjinnov-2021-000699
https://doi.org/10.1136/bmjinnov-2021-00... , adoption of detailed pre-consultation protocols²⁸28. Womack C, Farsin R, Farsad M, Chaudary N. Emerging alternatives to conventional clinic visits in the era of COVID-19: adoption of telehealth at VCU Adult Cystic Fibrosis Center. Int J Gen Med. 2020 Nov;13:1175-86. https://doi.org/10.2147/IJGM.S274193
https://doi.org/10.2147/IJGM.S274193... and hybrid care protocols, including face-to-face and online consultations, when necessary²³23. Ladin K, Porteny T, Perugini JM, Gonzales KM, Aufort KE, Levine SK, et al. Perceptions of telehealth vs in-person visits among older adults with advanced kidney disease, care partners, and clinicians. JAMA Netw Open. 2021 Dec;4(12):e2137193. https://doi.org/10.1001/jamanetworkopen.2021.37193
https://doi.org/10.1001/jamanetworkopen.... ,²⁶26. Tsutsui M, Gerayeli F, Sin DD. Pulmonary rehabilitation in a Post-COVID-19 world: telerehabilitation as a new standard in patients with COPD. Int J Chron Obstruct Pulmon Dis. 2021 Feb;16:379-91. https://doi.org/10.2147/COPD.S263031
https://doi.org/10.2147/COPD.S263031... , and the service performed by multiprofessional team²⁵25. Solomon GM, Bailey J, Lawlor J, Scalia P, Sawicki GS, Dowd C, et al. Patient and family experience of telehealth care delivery as part of the CF chronic care model early in the COVID-19 pandemic. J Cyst Fibros. 2021 Dec;20 Suppl 3:41-6. https://doi.org/10.1016/j.jcf.2021.09.005
https://doi.org/10.1016/j.jcf.2021.09.00... .

Regarding access to health services through telemedicine for patients with chronic diseases during the covid-19 pandemic, 88% of the articles reported access barriers to the use of telemedicine. These were: technological barriers resulting from digital exclusion²⁰20. Albert SL, Paul MM, Nguyen AM, Shelley DR, Berry CA. A qualitative study of high-performing primary care practices during the COVID-19 pandemic. BMC Fam Pract. 2021 Nov;22(1):237. https://doi.org/10.1186/s12875-021-01589-4
https://doi.org/10.1186/s12875-021-01589... ,²³23. Ladin K, Porteny T, Perugini JM, Gonzales KM, Aufort KE, Levine SK, et al. Perceptions of telehealth vs in-person visits among older adults with advanced kidney disease, care partners, and clinicians. JAMA Netw Open. 2021 Dec;4(12):e2137193. https://doi.org/10.1001/jamanetworkopen.2021.37193
https://doi.org/10.1001/jamanetworkopen.... ,²⁶26. Tsutsui M, Gerayeli F, Sin DD. Pulmonary rehabilitation in a Post-COVID-19 world: telerehabilitation as a new standard in patients with COPD. Int J Chron Obstruct Pulmon Dis. 2021 Feb;16:379-91. https://doi.org/10.2147/COPD.S263031
https://doi.org/10.2147/COPD.S263031... , internet access difficulties²³23. Ladin K, Porteny T, Perugini JM, Gonzales KM, Aufort KE, Levine SK, et al. Perceptions of telehealth vs in-person visits among older adults with advanced kidney disease, care partners, and clinicians. JAMA Netw Open. 2021 Dec;4(12):e2137193. https://doi.org/10.1001/jamanetworkopen.2021.37193
https://doi.org/10.1001/jamanetworkopen.... ,²⁸28. Womack C, Farsin R, Farsad M, Chaudary N. Emerging alternatives to conventional clinic visits in the era of COVID-19: adoption of telehealth at VCU Adult Cystic Fibrosis Center. Int J Gen Med. 2020 Nov;13:1175-86. https://doi.org/10.2147/IJGM.S274193
https://doi.org/10.2147/IJGM.S274193... ,³³33. Lewis A, Knight E, Bland M, Middleton J, Mitchell E, McCrum K, et al. Feasibility of an online platform delivery of pulmonary rehabilitation for individuals with chronic respiratory disease. BMJ Open Respir Res. 2021 Mar;8(1):e000880. https://doi.org/10.1136/bmjresp-2021-000880
https://doi.org/10.1136/bmjresp-2021-000... ,³⁵35. Wickerson L, Helm D, Gottesman C, Rozenberg D, Singer LG, Keshavjee S, et al. Telerehabilitation for lung transplant candidates and recipients during the COVID-19 pandemic: program evaluation. JMIR Mhealth Uhealth. 2021 Jun;9(6):e28708. https://doi.org/10.2196/28708
https://doi.org/10.2196/28708... , connection problems³⁶36. Alvarez-Risco A, Del-Aguila-Arcentales S, Yáñez JA. Telemedicine in Peru as a result of the COVID-19 pandemic: perspective from a country with limited internet access. Am J Trop Med Hyg. 2021 May;105(1):6-11. https://doi.org/10.4269/ajtmh.21-0255
https://doi.org/10.4269/ajtmh.21-0255... sociocultural barriers (low purchasing power being the main one)²³23. Ladin K, Porteny T, Perugini JM, Gonzales KM, Aufort KE, Levine SK, et al. Perceptions of telehealth vs in-person visits among older adults with advanced kidney disease, care partners, and clinicians. JAMA Netw Open. 2021 Dec;4(12):e2137193. https://doi.org/10.1001/jamanetworkopen.2021.37193
https://doi.org/10.1001/jamanetworkopen.... ,²⁷27. Uscher-Pines L, Thompson J, Taylor P, Dean K, Yuan T, Tong I, et al. Where virtual care was already a reality: experiences of a nationwide telehealth service provider during the COVID-19 pandemic. J Med Internet Res. 2020 Dec;22(12):e22727. https://doi.org/10.2196/22727
https://doi.org/10.2196/22727... ,³⁶36. Alvarez-Risco A, Del-Aguila-Arcentales S, Yáñez JA. Telemedicine in Peru as a result of the COVID-19 pandemic: perspective from a country with limited internet access. Am J Trop Med Hyg. 2021 May;105(1):6-11. https://doi.org/10.4269/ajtmh.21-0255
https://doi.org/10.4269/ajtmh.21-0255... ,³⁷37. Deng D, Liang A, Chui JN, Wong G, Cooper TE. The COVID-19 pandemic and access to health care in people with chronic kidney disease: A systematic review and meta-analysis. Nephrology (Carlton). 2022 May;27(5):410-20. https://doi.org/10.1111/nep.14016; Online ahead of print
https://doi.org/10.1111/nep.14016... , related to language²³23. Ladin K, Porteny T, Perugini JM, Gonzales KM, Aufort KE, Levine SK, et al. Perceptions of telehealth vs in-person visits among older adults with advanced kidney disease, care partners, and clinicians. JAMA Netw Open. 2021 Dec;4(12):e2137193. https://doi.org/10.1001/jamanetworkopen.2021.37193
https://doi.org/10.1001/jamanetworkopen.... ,²⁹29. Turner K, Bobonis Babilonia M, Naso C, Nguyen O, Gonzalez BD, Oswald LB, et al. Health care providers’ and professionals’ experiences with telehealth oncology implementation during the COVID-19 pandemic: a qualitative study. J Med Internet Res. 2022 Jan;24(1):e29635. https://doi.org/10.2196/29635
https://doi.org/10.2196/29635... , age²⁰20. Albert SL, Paul MM, Nguyen AM, Shelley DR, Berry CA. A qualitative study of high-performing primary care practices during the COVID-19 pandemic. BMC Fam Pract. 2021 Nov;22(1):237. https://doi.org/10.1186/s12875-021-01589-4
https://doi.org/10.1186/s12875-021-01589... ,³⁴34. Kayser MZ, Valtin C, Greer M, Karow B, Fuge J, Gottlieb J. Video consultation during the COVID-19 pandemic: a single center’s experience with lung transplant recipients. Telemed J E Health. 2021 Jul;27(7):807-15. https://doi.org/10.1089/tmj.2020.0170
https://doi.org/10.1089/tmj.2020.0170... , disability²⁹29. Turner K, Bobonis Babilonia M, Naso C, Nguyen O, Gonzalez BD, Oswald LB, et al. Health care providers’ and professionals’ experiences with telehealth oncology implementation during the COVID-19 pandemic: a qualitative study. J Med Internet Res. 2022 Jan;24(1):e29635. https://doi.org/10.2196/29635
https://doi.org/10.2196/29635... , the type of health insurance and the telemedicine funding, as well as the assistance access (22%). Among the most important are the limitation in the physical examination of the patient²⁵25. Solomon GM, Bailey J, Lawlor J, Scalia P, Sawicki GS, Dowd C, et al. Patient and family experience of telehealth care delivery as part of the CF chronic care model early in the COVID-19 pandemic. J Cyst Fibros. 2021 Dec;20 Suppl 3:41-6. https://doi.org/10.1016/j.jcf.2021.09.005
https://doi.org/10.1016/j.jcf.2021.09.00... ,²⁸28. Womack C, Farsin R, Farsad M, Chaudary N. Emerging alternatives to conventional clinic visits in the era of COVID-19: adoption of telehealth at VCU Adult Cystic Fibrosis Center. Int J Gen Med. 2020 Nov;13:1175-86. https://doi.org/10.2147/IJGM.S274193
https://doi.org/10.2147/IJGM.S274193... , lack of professionals²⁶26. Tsutsui M, Gerayeli F, Sin DD. Pulmonary rehabilitation in a Post-COVID-19 world: telerehabilitation as a new standard in patients with COPD. Int J Chron Obstruct Pulmon Dis. 2021 Feb;16:379-91. https://doi.org/10.2147/COPD.S263031
https://doi.org/10.2147/COPD.S263031... and aspects regarding specifically the disease or age group, such as hearing problems²³23. Ladin K, Porteny T, Perugini JM, Gonzales KM, Aufort KE, Levine SK, et al. Perceptions of telehealth vs in-person visits among older adults with advanced kidney disease, care partners, and clinicians. JAMA Netw Open. 2021 Dec;4(12):e2137193. https://doi.org/10.1001/jamanetworkopen.2021.37193
https://doi.org/10.1001/jamanetworkopen.... . All these barriers are mainly related to vulnerable populations, including refugee and immigrant groups²⁰20. Albert SL, Paul MM, Nguyen AM, Shelley DR, Berry CA. A qualitative study of high-performing primary care practices during the COVID-19 pandemic. BMC Fam Pract. 2021 Nov;22(1):237. https://doi.org/10.1186/s12875-021-01589-4
https://doi.org/10.1186/s12875-021-01589... .

In addition, aspects that facilitate patients’ access to health care through telemedicine – such as expanding the offer to residents in remote or rural areas (16%)²⁴24. McGinley MP, Ontaneda D, Wang Z, Weber M, Shook S, Stanton M, et al. Teleneurology as a solution for outpatient care during the COVID-19 pandemic. Telemed J E Health. 2020 Dec;26(12):1537-9. https://doi.org/10.1089/tmj.2020.0137
https://doi.org/10.1089/tmj.2020.0137... ,³¹31. Gudi N, Konapur R, John O, Sarbadhikari S, Landry M. Telemedicine supported strengthening of primary care in WHO South East Asia region: lessons from the COVID-19 pandemic experiences. BMJ Innov. 2021;7(3):580-5. https://doi.org/10.1136/bmjinnov-2021-000699
https://doi.org/10.1136/bmjinnov-2021-00... , factors related to saving time and resources with commuting²⁴24. McGinley MP, Ontaneda D, Wang Z, Weber M, Shook S, Stanton M, et al. Teleneurology as a solution for outpatient care during the COVID-19 pandemic. Telemed J E Health. 2020 Dec;26(12):1537-9. https://doi.org/10.1089/tmj.2020.0137
https://doi.org/10.1089/tmj.2020.0137... (11%) and the increased involvement of family members and caregivers²⁰20. Albert SL, Paul MM, Nguyen AM, Shelley DR, Berry CA. A qualitative study of high-performing primary care practices during the COVID-19 pandemic. BMC Fam Pract. 2021 Nov;22(1):237. https://doi.org/10.1186/s12875-021-01589-4
https://doi.org/10.1186/s12875-021-01589... (5%) – are pointed out as benefits of the implementation of the remote system. With regard to the future of telemedicine in health systems, the recommendation for the development of guidelines and protocols enabling safe and effective service provision with good digital infrastructure is identified in 83% of studies.

DISCUSSION

From the mapping and analysis of the data provided by the literature used in this review, we identified the exponential increase in the use of telemedicine and other remote care modalities during the covid-19 pandemic aimed at the care of chronic patients in continuous care. We know that this is an even more comprehensive concept, if we consider here the use of telemedicine forms excluded by the adopted methodological criteria.

After the organization and analysis of the results, we identified three dimensions: trends in telemedicine, innovations in care and access barriers, as shown in Figure 2.

Trends in Telemedicine

The scope of the selected articles highlights the predominance of studies produced in the United States, especially in scenarios where telemedicine had already been used before the pandemic. The availability of technological structure made it possible to quickly implement²⁵25. Solomon GM, Bailey J, Lawlor J, Scalia P, Sawicki GS, Dowd C, et al. Patient and family experience of telehealth care delivery as part of the CF chronic care model early in the COVID-19 pandemic. J Cyst Fibros. 2021 Dec;20 Suppl 3:41-6. https://doi.org/10.1016/j.jcf.2021.09.005
https://doi.org/10.1016/j.jcf.2021.09.00... ,³²32. Volpato E, Centanni S, Banfi P, D’Antonio S, Peterle E, Bugliaro F, et al. Narrative analysis of the impact of COVID-19 on patients with chronic obstructive pulmonary disease, their caregivers, and healthcare professionals in Italy. Int J Chron Obstruct Pulmon Dis. 2021 Jul;16:2181-201. https://doi.org/10.2147/COPD.S312372
https://doi.org/10.2147/COPD.S312372... these procedures in the USA. In addition, the incorporation of telemedicine in the list of reimbursable procedures by US health plans has served as an incentive since the beginning of the pandemic²⁰20. Albert SL, Paul MM, Nguyen AM, Shelley DR, Berry CA. A qualitative study of high-performing primary care practices during the COVID-19 pandemic. BMC Fam Pract. 2021 Nov;22(1):237. https://doi.org/10.1186/s12875-021-01589-4
https://doi.org/10.1186/s12875-021-01589... ,²¹21. Boyce DM, Thomashow BM, Sullivan J, Tal-Singer R. New adopters of telemedicine during the Coronavirus-19 pandemic in respondents to an online community survey: the case for access to remote management tools for individuals with chronic obstructive pulmonary disease. Chronic Obstr Pulm Dis (Miami). 2021 Apr;8(2):213-8. https://doi.org/10.15326/jcopdf.2020.0181
https://doi.org/10.15326/jcopdf.2020.018... . A study involving a large American telehealth provider also highlighted the increase in demand for care due to chronic diseases and mental health issues, surpassing the search for care motivated by the coronavirus²⁷27. Uscher-Pines L, Thompson J, Taylor P, Dean K, Yuan T, Tong I, et al. Where virtual care was already a reality: experiences of a nationwide telehealth service provider during the COVID-19 pandemic. J Med Internet Res. 2020 Dec;22(12):e22727. https://doi.org/10.2196/22727
https://doi.org/10.2196/22727... .

On the other hand, in many other locations, such as in China, latent structures gained visibility and could be used in the care of patients because of the health emergency. The authors argue that the structures unveiled in the pandemic should be kept after the mitigation of cases and control of the situation³⁸38. Vidal-Alaball J, Acosta-Roja R, Pastor Hernández N, Sanchez Luque U, Morrison D, Narejos Pérez S, et al. Telemedicine in the face of the COVID-19 pandemic. Aten Primaria. 2020;52(6):418-22. https://doi.org/10.1016/j.aprim.2020.04.003
https://doi.org/10.1016/j.aprim.2020.04.... .

We also observed a predominance of papers on the use of telemedicine aimed at the care of patients with chronic respiratory diseases (CRD), a condition that appears among the main causes of morbidity and mortality worldwide. Commonly found, COPD and asthma are among the 20 diseases that disable the most amount of people on a global scale³⁹39. Soriano JB, Abajobir AA, Abate KH, Abera SF, Agrawal A, Ahmed MB, et al. Global, regional, and national deaths, prevalence, disability-adjusted life years, and years lived with disability for chronic obstructive pulmonary disease and asthma, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Respir Med. 2017 Sep;5(9):691-706. https://doi.org/10.1016/S2213-2600(17)30293-X
https://doi.org/10.1016/S2213-2600(17)30... . The use of telemedicine in pulmonology is not recent: Zamith and Gomes⁴⁰40. Zamith M, Gomes MJ. Novas tecnologias da informação em pneumologia. Rev Port Pneumol. 2005;11(3):S21-8. https://doi.org/10.1016/S0873-2159(15)30544-4
https://doi.org/10.1016/S0873-2159(15)30... identified studies performed since 1993 containing the association of words “telemedicine” and “lung”. Additionally, the shortage of professionals specialized in pulmonology had already been observed years before the pandemic, and studies that pointed to the use of technological arrangements that could contribute to improving this scenario and guarantee patient access had already been published, such as the described experiences of matrix support and shared care in pulmonology⁴¹41. Martins SM, Salibe-Filho W, Tonioli LP, Pfingesten LE, Braz PD, McDonnell J, et al. Implementation of ‘matrix support’ (collaborative care) to reduce asthma and COPD referrals and improve primary care management in Brazil: a pilot observational study. NPJ Prim Care Respir Med. 2016 Aug;26(1):16047. https://doi.org/10.1038/npjpcrm.2016.47
https://doi.org/10.1038/npjpcrm.2016.47... ,⁴²42. Freire MP, Louvison M, Feuerwerker LC, Chioro A, Bertussi D. Regulação do cuidado em redes de atenção: importância de novos arranjos tecnológicos. Saude Soc. 2020;29(3):e190682. https://doi.org/10.1590/s0104-12902020190682
https://doi.org/10.1590/s0104-1290202019... .

Besides, the increased demand caused by the pandemic and the potential risk to patients with CRD are also points that contribute to the understanding of the predominance of studies in Pulmonology. Pulmonary telerehabilitation, on the other hand, showed promising results regarding the progression of exercises and improvement of disease indicators²⁴24. McGinley MP, Ontaneda D, Wang Z, Weber M, Shook S, Stanton M, et al. Teleneurology as a solution for outpatient care during the COVID-19 pandemic. Telemed J E Health. 2020 Dec;26(12):1537-9. https://doi.org/10.1089/tmj.2020.0137
https://doi.org/10.1089/tmj.2020.0137... , although there are limitations identified in the access of patients²⁷27. Uscher-Pines L, Thompson J, Taylor P, Dean K, Yuan T, Tong I, et al. Where virtual care was already a reality: experiences of a nationwide telehealth service provider during the COVID-19 pandemic. J Med Internet Res. 2020 Dec;22(12):e22727. https://doi.org/10.2196/22727
https://doi.org/10.2196/22727... .

In Italy, patients with COPD reported receiving twice as many telemedicine visits from pulmonologists as from family doctors³²32. Volpato E, Centanni S, Banfi P, D’Antonio S, Peterle E, Bugliaro F, et al. Narrative analysis of the impact of COVID-19 on patients with chronic obstructive pulmonary disease, their caregivers, and healthcare professionals in Italy. Int J Chron Obstruct Pulmon Dis. 2021 Jul;16:2181-201. https://doi.org/10.2147/COPD.S312372
https://doi.org/10.2147/COPD.S312372... . The possibility of providing self-monitoring instruments and the good results the use of equipment at home have demonstrated seem to be factors that give advantages in the monitoring of chronic respiratory diseases, when talking about advances in telemedicine³⁴34. Kayser MZ, Valtin C, Greer M, Karow B, Fuge J, Gottlieb J. Video consultation during the COVID-19 pandemic: a single center’s experience with lung transplant recipients. Telemed J E Health. 2021 Jul;27(7):807-15. https://doi.org/10.1089/tmj.2020.0170
https://doi.org/10.1089/tmj.2020.0170... .

Innovations in Care

The social distancing recommendation adopted by several countries during the pandemic had great adherence among patients with chronic diseases and accentuated difficulties in accessing care, warning about the risk of increased morbidity, disability and avoidable mortality⁴³43. Kluge HH, Wickramasinghe K, Rippin HL, Mendes R, Peters DH, Kontsevaya A, et al. Prevention and control of non-communicable diseases in the COVID-19 response. Lancet. 2020 May;395(10238):1678-80. https://doi.org/10.1016/S0140-6736(20)31067-9
https://doi.org/10.1016/S0140-6736(20)31... . Brazilian authors emphasize that it is necessary to discuss policies and identify strategies that allow continuity of care, minimizing interruptions and adapting to the new scenario, taking risks of reinforcing or widening inequalities⁴⁴44. Malta DC, Gomes CS, Silva AG, Cardoso LSM, Barros MBA, Lima MG, et al. Uso dos serviços de saúde e adesão ao distanciamento social por adultos com doenças crônicas na pandemia de COVID-19, Brasil, 2020. Cien Saúde Coletiva, 26(7), 2833-2842. https://doi.org/10.1590/1413-81232021267.00602021
https://doi.org/10.1590/1413-81232021267... ,⁴⁵45. Catapan SC, Calvo MC. Contexto macro-institucional brasileiro para implantação da teleconsulta médica. Braz J Health Rev. 2022;5(1):27-46. https://doi.org/10.34119/bjhrv5n1-003
https://doi.org/10.34119/bjhrv5n1-003... .

Based on the conjuncture established by covid-19, the first publications⁴⁶46. Lee A, Morling J. COVID19: the need for public health in a time of emergency. Public Health. 2020 May;182:188-9. https://doi.org/10.1016/j.puhe.2020.03.027
https://doi.org/10.1016/j.puhe.2020.03.0... ,⁴⁷47. Lee D, Choi B. Policies and innovations to battle Covid-19: a case study of South Korea. Health Policy Technol. 2020 Dec;9(4):587-97. https://doi.org/10.1016/j.hlpt.2020.08.010
https://doi.org/10.1016/j.hlpt.2020.08.0... already evidenced the urgency in identifying possibilities for care, encouraging innovations, in an attempt to circumvent the imposed difficulties. Based on the results, telemedicine, generally, presented itself as one of the most important of these innovations, offering powerful mechanisms to act in a scenario of fast-paced contamination¹¹11. Eze ND, Mateus C, Hashiguchi TCOI. Telemedicine in the OECD: an umbrella review of clinical and cost-effectiveness, patient experience and implementation. PLoS One. 2020 Aug;15(8):e0237585. https://doi.org/10.1371/journal.pone.0237585
https://doi.org/10.1371/journal.pone.023... ,²¹21. Boyce DM, Thomashow BM, Sullivan J, Tal-Singer R. New adopters of telemedicine during the Coronavirus-19 pandemic in respondents to an online community survey: the case for access to remote management tools for individuals with chronic obstructive pulmonary disease. Chronic Obstr Pulm Dis (Miami). 2021 Apr;8(2):213-8. https://doi.org/10.15326/jcopdf.2020.0181
https://doi.org/10.15326/jcopdf.2020.018... ,³¹31. Gudi N, Konapur R, John O, Sarbadhikari S, Landry M. Telemedicine supported strengthening of primary care in WHO South East Asia region: lessons from the COVID-19 pandemic experiences. BMJ Innov. 2021;7(3):580-5. https://doi.org/10.1136/bmjinnov-2021-000699
https://doi.org/10.1136/bmjinnov-2021-00... ,⁴⁸48. Rockwell KL, Gilroy AS. Incorporating telemedicine as part of COVID-19 outbreak response systems. Am J Manag Care. 2020 Apr;26(4):147-8. https://doi.org/10.37765/ajmc.2020.42784
https://doi.org/10.37765/ajmc.2020.42784... ,⁴⁹49. Patel SY, Mehrotra A, Huskamp HA, Uscher-Pines L, Ganguli I, Barnett ML. Trends in outpatient care delivery and telemedicine during the COVID-19 pandemic in the US. JAMA Intern Med. 2021 Mar;181(3):388-91. https://doi.org/10.1001/jamainternmed.2020.5928
https://doi.org/10.1001/jamainternmed.20... . Although it was not exactly a new arrangement, telemedicine contributed to the diversification of care, using characteristics such as versatility and broad capacity to reach different populations and health needs. The described innovations demonstrated the importance of offering patient-centered, multilevel, multidisciplinary and continuous care³²32. Volpato E, Centanni S, Banfi P, D’Antonio S, Peterle E, Bugliaro F, et al. Narrative analysis of the impact of COVID-19 on patients with chronic obstructive pulmonary disease, their caregivers, and healthcare professionals in Italy. Int J Chron Obstruct Pulmon Dis. 2021 Jul;16:2181-201. https://doi.org/10.2147/COPD.S312372
https://doi.org/10.2147/COPD.S312372... .

The identification of innovative structural arrangements and innovative care arrangements alludes, although in a rudimentary way, to the models of care production and the importance of living labor in the process of care production⁵⁰50. Franco TB, Merhy EE. Cartografias do trabalho e cuidado em saúde. Tempus - Actas Saúde Pública. 2021;6(2):151-163. https://doi.org/10.18569/tempus.v6i2.1120
https://doi.org/10.18569/tempus.v6i2.112... . Thus, considering that certain arrangements relied more heavily on hegemonic instruments, tools and knowledge – also known as “Hard technologies “ and ”Soft-hard Technologies” – while others were built based on relational aspects, produced in the overlap between health professionals and the patient – known as “Soft technologies”⁵¹51. Merhy EE. Um ensaio sobre o médico e suas valises tecnológicas: contribuições para compreender as reestruturações produtivas do setor saúde. Interface (Botucatu). 2000;4(6):109-16. https://doi.org/10.1590/S1414-32832000000100009
https://doi.org/10.1590/S1414-3283200000... . From this perspective, we identified relevant aspects in each one of them.

The innovative structural arrangements, represented here by sending equipment to the patients’ homes, online prescriptions, drive thru laboratories, among others, raise the issue of telemedicine regulation and funding, inside and outside Brazil. Aspects such as differences in nomenclature and scope, security and protection of patient data, and compensation of services often represent obstacles that must be overcome through defining specific policies and broadly discussing the topic⁴⁵45. Catapan SC, Calvo MC. Contexto macro-institucional brasileiro para implantação da teleconsulta médica. Braz J Health Rev. 2022;5(1):27-46. https://doi.org/10.34119/bjhrv5n1-003
https://doi.org/10.34119/bjhrv5n1-003... ,⁵²52. Xu J, Willging A, Bramstedt KA. A scoping review of the ethical issues within telemedicine: lessons from COVID-19 pandemic. J Health Soc Sci. 2021;6(1):31-40..

In Brazil, the regulation in health had been discussed and was moving forward in the Federal Council of Medicine, which published resolution nr. 2.227/2018 at the end of the year, defining important aspects of telemedicine practice. However, institutional disputes motivated its repeal a few days later, conserving the regulatory gap of telemedicine in Brazil⁵³53. Wen CL. Telemedicina do presente para o ecossistema de saúde conectada 5.0. São Paulo: Instituto de Estudos de Saúde Suplementar; 2020.. With the pandemic outbreak, the Ministry of Health published the ordinance nr. 467, on March 20, 2020⁵⁴54. Ministério da Saúde (BR). Portaria no 467, de 20 de março de 2020. Dispõe, em caráter excepcional e temporário, sobre as ações de Telemedicina, com o objetivo de regulamentar e operacionalizar as medidas de enfrentamento da emergência de saúde pública de importância internacional previstas no art. 3º da Lei nº 13.979, de 6 de fevereiro de 2020, decorrente da epidemia de Covid-19. Diário Oficial União, 21 mar 2021., with temporary provisions for telemedicine actions, supported by Law nr. 13.979, of February 06, 2020⁵⁵55. Brasil. Lei no 13.979, de 6 de fevereiro de 2020. Dispõe sobre as medidas para enfrentamento da emergência de saúde pública de importância internacional decorrente do coronavírus responsável pelo surto de 2019. Diário Oficial União. 7 fev 2020., which defined the health emergency in Brazil. The legal device supported the use of telemedicine in Brazil during the emergency, which was declared terminated by the Ministry of Health in the ordinance nr. 913 of April 22, 2022, returning to the Federal Council of Medicine (CFM) the task of regulating telemedicine. More recently, the CFM published resolution nr. 2.314/2022, regulating telemedicine, which still lacks detailed analysis. At the same time, legislative bodies debate a bill on the topic, which expresses the timeliness, urgency and controversy surrounding it.

On the other hand, innovative care arrangements, in turn, portray aspects of the relationships and micro politics of health services⁵⁶56. Feuerwerker LCM. Micropolítica e saúde: produção do cuidado, gestão e formação. Porto Alege: Rede Unida; 2014.. The results found in this review express the tensions experienced in the daily life of services, from bureaucracy to the freedom experienced by health professionals, rooting from unknown situations. The professional performance took place in adverse conditions, outside the comfort zone and with the need to adapt to the unusual scenario. These circumstances made everyday tasks more flexible and enabled the professionals to assume new roles⁸8. Stralen AC, Carvalho CL, Girardi SN, Massote AW, Cherchiglia ML. Estratégias internacionais de flexibilização da regulação da prática de profissionais de saúde em resposta à pandemia da COVID-19: revisão de escopo. Cad Saúde Pública. 2022;38(2):e00116321. https://doi.org/10.1590/0102-311x00116321
https://doi.org/10.1590/0102-311x0011632... .

In many cases, since there was little regulation and/or a character of exception leveraged by the pandemic, new possibilities of care have emerged, in addition to experiments and incorporation of new protocols²⁸28. Womack C, Farsin R, Farsad M, Chaudary N. Emerging alternatives to conventional clinic visits in the era of COVID-19: adoption of telehealth at VCU Adult Cystic Fibrosis Center. Int J Gen Med. 2020 Nov;13:1175-86. https://doi.org/10.2147/IJGM.S274193
https://doi.org/10.2147/IJGM.S274193... . The “temporal window of opportunities”⁵⁷57. Merhy EE, Bertussi DC, Santos MLM, Rosa NSF, Slomp Junior H, Seixas CT. Pandemia, Sistema Único de Saúde (SUS) e Saúde Coletiva: com-posições e aberturas para mundos outros. Interface (Botucatu), 2022;26:e210491. https://doi.org/10.1590/interface.210491
https://doi.org/10.1590/interface.210491... , which opened due to the health crisis, brings complex existential challenges to Public Health in the “post-” pandemic moment. Decentralized caring and integrative practices⁴²42. Freire MP, Louvison M, Feuerwerker LC, Chioro A, Bertussi D. Regulação do cuidado em redes de atenção: importância de novos arranjos tecnológicos. Saude Soc. 2020;29(3):e190682. https://doi.org/10.1590/s0104-12902020190682
https://doi.org/10.1590/s0104-1290202019... are important elements in the analysis of the response to the pandemic.

Finally, the results showed that telemedicine practices have good acceptance rates, both among patients and families and among health professionals and managers²⁰20. Albert SL, Paul MM, Nguyen AM, Shelley DR, Berry CA. A qualitative study of high-performing primary care practices during the COVID-19 pandemic. BMC Fam Pract. 2021 Nov;22(1):237. https://doi.org/10.1186/s12875-021-01589-4
https://doi.org/10.1186/s12875-021-01589... . On the other hand, they require in-depth studies regarding cost-effectiveness, quality and user satisfaction; however, the unavailability of data weakens their advancement, regulation, financing and use⁵⁸58. Rhoden PA, Bonilha H, Harvey J. Patient satisfaction of Telemedicine remote patient monitoring: a systematic review. Telemed J E Health. 2022 Sep;28(9):1332-41. https://doi.org/10.1089/tmj.2021.0434
https://doi.org/10.1089/tmj.2021.0434... .

Access Barriers

The trends and innovations arising from the use of telemedicine for the care of chronically ill patients during the pandemic identified in this review are relevant and offer clues both for policy formulation and for the development of new studies. However, regarding access to health care for the chronically ill using telemedicine, most of the papers included in this review point to numerous barriers²⁰20. Albert SL, Paul MM, Nguyen AM, Shelley DR, Berry CA. A qualitative study of high-performing primary care practices during the COVID-19 pandemic. BMC Fam Pract. 2021 Nov;22(1):237. https://doi.org/10.1186/s12875-021-01589-4
https://doi.org/10.1186/s12875-021-01589... . Observing that telemedicine has expanded its borders and is consolidating itself as a care arrangement(s) for chronic diseases⁵⁹59. Caetano R, Silva AB, Guedes AC, Paiva CC, Ribeiro GD, Santos DL, et al. Desafios e oportunidades para telessaúde em tempos da pandemia pela COVID-19: uma reflexão sobre os espaços e iniciativas no contexto brasileiro. Cad Saúde Pública. 2020;36(5):e00088920. https://doi.org/10.1590/0102-311x00088920
https://doi.org/10.1590/0102-311x0008892... should not be dissociated from the dimension of access and, especially, from the identified barriers. The formulation and implementation of health policies based on technology-mediated care, such as telemedicine and its variations, can both contribute to reducing barriers in health access and highlight inequalities that may compromise the universality of access to health services.

Analyzing the effect that the pandemic has produced on access to health is one of the main current challenges for building resilient health systems. For some authors⁶⁰60. Massuda A, Malik AM, Vecina Neto G, Tasca R, Ferreira Junior WC. A resiliência do Sistema Único de Saúde frente à COVID-19. Cadernos EBAPE.BR. 2021;19(spe):735-744. https://doi.org/10.1590/1679-395120200185
https://doi.org/10.1590/1679-39512020018... , the resilience of health systems goes beyond the “fulfillment of the right to health” and encompasses social and economic activities, reproducing the experience of the pandemic. Therefore, early identification of the barriers caused by the use of telemedicine in the health care of chronic patients can prevent the increase of inequities in access to care. In addition, it is essential to include the patient’s dimension, with its diagnostic specificities, in the formulation of policies and protocols²¹21. Boyce DM, Thomashow BM, Sullivan J, Tal-Singer R. New adopters of telemedicine during the Coronavirus-19 pandemic in respondents to an online community survey: the case for access to remote management tools for individuals with chronic obstructive pulmonary disease. Chronic Obstr Pulm Dis (Miami). 2021 Apr;8(2):213-8. https://doi.org/10.15326/jcopdf.2020.0181
https://doi.org/10.15326/jcopdf.2020.018... .

Although the main challenge regarding access is linked to digital illiteracy (or digital exclusion), the gap evidenced by technology reflects social and health inequalities of the population, whose reduction should guide the construction of quality health systems, with guaranteed access and equity.

However, we also identified factors that can help the patient’s access ²⁰20. Albert SL, Paul MM, Nguyen AM, Shelley DR, Berry CA. A qualitative study of high-performing primary care practices during the COVID-19 pandemic. BMC Fam Pract. 2021 Nov;22(1):237. https://doi.org/10.1186/s12875-021-01589-4
https://doi.org/10.1186/s12875-021-01589... ,²⁴24. McGinley MP, Ontaneda D, Wang Z, Weber M, Shook S, Stanton M, et al. Teleneurology as a solution for outpatient care during the COVID-19 pandemic. Telemed J E Health. 2020 Dec;26(12):1537-9. https://doi.org/10.1089/tmj.2020.0137
https://doi.org/10.1089/tmj.2020.0137... ,²⁵25. Solomon GM, Bailey J, Lawlor J, Scalia P, Sawicki GS, Dowd C, et al. Patient and family experience of telehealth care delivery as part of the CF chronic care model early in the COVID-19 pandemic. J Cyst Fibros. 2021 Dec;20 Suppl 3:41-6. https://doi.org/10.1016/j.jcf.2021.09.005
https://doi.org/10.1016/j.jcf.2021.09.00... ,³¹31. Gudi N, Konapur R, John O, Sarbadhikari S, Landry M. Telemedicine supported strengthening of primary care in WHO South East Asia region: lessons from the COVID-19 pandemic experiences. BMJ Innov. 2021;7(3):580-5. https://doi.org/10.1136/bmjinnov-2021-000699
https://doi.org/10.1136/bmjinnov-2021-00... , and they can serve as a starting point for policymaking and service implementation. The improvement of the use of digital technologies is central to this discussion and demands political and management efforts in digital infrastructure investment²⁴24. McGinley MP, Ontaneda D, Wang Z, Weber M, Shook S, Stanton M, et al. Teleneurology as a solution for outpatient care during the COVID-19 pandemic. Telemed J E Health. 2020 Dec;26(12):1537-9. https://doi.org/10.1089/tmj.2020.0137
https://doi.org/10.1089/tmj.2020.0137... ,²⁸28. Womack C, Farsin R, Farsad M, Chaudary N. Emerging alternatives to conventional clinic visits in the era of COVID-19: adoption of telehealth at VCU Adult Cystic Fibrosis Center. Int J Gen Med. 2020 Nov;13:1175-86. https://doi.org/10.2147/IJGM.S274193
https://doi.org/10.2147/IJGM.S274193... ,³¹31. Gudi N, Konapur R, John O, Sarbadhikari S, Landry M. Telemedicine supported strengthening of primary care in WHO South East Asia region: lessons from the COVID-19 pandemic experiences. BMJ Innov. 2021;7(3):580-5. https://doi.org/10.1136/bmjinnov-2021-000699
https://doi.org/10.1136/bmjinnov-2021-00... ,³⁷37. Deng D, Liang A, Chui JN, Wong G, Cooper TE. The COVID-19 pandemic and access to health care in people with chronic kidney disease: A systematic review and meta-analysis. Nephrology (Carlton). 2022 May;27(5):410-20. https://doi.org/10.1111/nep.14016; Online ahead of print
https://doi.org/10.1111/nep.14016... .

We concluded that the increase in telemedicine throughout the covid-19 pandemic presented innovative technological arrangements that, at the same time, collaborated with the expansion of access and with the implementation of this modality of care in the daily life of Health Services. However, issues related to digital exclusion and sociocultural and care conditions were pointed out as access barriers to the use of telemedicine that must be overcome in order to expand, in fact, its use value, caregiver potential and innovation in health systems.

The implementation of specific policies and the elaboration of protocols that guide the work of professionals, particularly for chronic conditions, are important recommendations for incorporating telemedicine as a safe, accessible and care-producing technology for health systems and services around the world.

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