Editorial
Telemedicine in clinical practice: Barriers and risks
La telemedicina en el ejercicio asistencial: barreras y riesgos
Read
Not available
Timeswas read the article
Total PDF
Total HTML
Share statistics
array:24 [ "pii" => "S2387020624000111" "issn" => "23870206" "doi" => "10.1016/j.medcle.2023.10.007" "estado" => "S300" "fechaPublicacion" => "2024-02-09" "aid" => "6458" "copyright" => "Elsevier España, S.L.U.. All rights reserved" "copyrightAnyo" => "2023" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "edi" "cita" => "Med Clin. 2024;162:123-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0025775323006139" "issn" => "00257753" "doi" => "10.1016/j.medcli.2023.10.012" "estado" => "S300" "fechaPublicacion" => "2024-02-09" "aid" => "6458" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "edi" "cita" => "Med Clin. 2024;162:123-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "La telemedicina en el ejercicio asistencial: barreras y riesgos" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "123" "paginaFinal" => "125" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Telemedicine in clinical practice: Barriers and risks" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ramón Puchades, Ismael Said-Criado" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Ramón" "apellidos" => "Puchades" ] 1 => array:2 [ "nombre" => "Ismael" "apellidos" => "Said-Criado" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020624000111" "doi" => "10.1016/j.medcle.2023.10.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020624000111?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775323006139?idApp=UINPBA00004N" "url" => "/00257753/0000016200000003/v1_202402020520/S0025775323006139/v1_202402020520/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S238702062400007X" "issn" => "23870206" "doi" => "10.1016/j.medcle.2023.08.007" "estado" => "S300" "fechaPublicacion" => "2024-02-09" "aid" => "6416" "copyright" => "The Author(s)" "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Med Clin. 2024;162:126-33" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Update in the management of chronic thrombo-embolic pulmonary hypertension" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "126" "paginaFinal" => "133" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Actualización del abordaje de la hipertensión pulmonar tromboembólica crónica" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3187 "Ancho" => 2917 "Tamanyo" => 375179 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diagnostic algorithm for chronic thromboembolic pulmonary hypertension in patients with a history of pulmonary embolism.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Adapted from Konstantinides et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">CTEPH: chronic thromboembolic pulmonary hypertension; CPET: cardiopulmonary exercise test; PE: pulmonary embolism; PH: pulmonary hypertension; TTE: transthoracic echocardiography; V/Q LS: ventilation/perfusion pulmonary scintigraphy.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jesús Ribas Sola, Miguel Ángel Sánchez-Corral Mena, Antoni Riera-Mestre" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Jesús" "apellidos" => "Ribas Sola" ] 1 => array:2 [ "nombre" => "Miguel Ángel" "apellidos" => "Sánchez-Corral Mena" ] 2 => array:2 [ "nombre" => "Antoni" "apellidos" => "Riera-Mestre" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775323005456" "doi" => "10.1016/j.medcli.2023.08.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775323005456?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702062400007X?idApp=UINPBA00004N" "url" => "/23870206/0000016200000003/v2_202402160843/S238702062400007X/v2_202402160843/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2387020624000159" "issn" => "23870206" "doi" => "10.1016/j.medcle.2023.11.004" "estado" => "S300" "fechaPublicacion" => "2024-02-09" "aid" => "6482" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Med Clin. 2024;162:118-22" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Brief report</span>" "titulo" => "Liraglutide for the treatment of obesity among patients with hidradenitis suppurativa" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "118" "paginaFinal" => "122" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Liraglutida en el tratamiento de la obesidad en pacientes con hidradenitis supurativa" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3364 "Ancho" => 2458 "Tamanyo" => 382887 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Changes in anthropometric variables and related changes in PRO questionnaires following treatment with liraglutide 3<span class="elsevierStyleHsp" style=""></span>mg o.d. in patients with HS. Blue box: baseline; Orange box: 3 months. BDI: Beck Depression Inventory; DLQI: Dermatology Life Quality Index; VAS: Visual Analog Scale.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Joana Nicolau, Antoni Nadal, Pilar Sanchís, Antelm Pujol, Lluís Masmiquel, Cristina Nadal" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Joana" "apellidos" => "Nicolau" ] 1 => array:2 [ "nombre" => "Antoni" "apellidos" => "Nadal" ] 2 => array:2 [ "nombre" => "Pilar" "apellidos" => "Sanchís" ] 3 => array:2 [ "nombre" => "Antelm" "apellidos" => "Pujol" ] 4 => array:2 [ "nombre" => "Lluís" "apellidos" => "Masmiquel" ] 5 => array:2 [ "nombre" => "Cristina" "apellidos" => "Nadal" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020624000159?idApp=UINPBA00004N" "url" => "/23870206/0000016200000003/v2_202402160843/S2387020624000159/v2_202402160843/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Telemedicine in clinical practice: Barriers and risks" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "123" "paginaFinal" => "125" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ramón Puchades, Ismael Said-Criado" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Ramón" "apellidos" => "Puchades" "email" => array:1 [ 0 => "rpuchades@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Ismael" "apellidos" => "Said-Criado" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Urgencias, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Grupo de Trabajo de Medicina Digital de la Sociedad Española de Medicina Interna" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La telemedicina en el ejercicio asistencial: barreras y riesgos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">“Medicine is the only profession of universal character, as it follows the same methods, acts with the same objectives and seeks the same goals and ends, regardless of where it’s practiced”.</p>William Osler.</span></p><p id="par0005" class="elsevierStylePara elsevierViewall">Within the development of new technologies and their application in the field of health, telemedicine has been progressively implemented in daily clinical healthcare practice as part of the new communication tools. With the recent COVID-19 pandemic, the process has accelerated, driven by the context, urgency and need.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This experience―, in addition to its positive aspects―, has also shown us the limitations and areas for improvement in relation to the use of telemedicine, which requires regulation and adaptation for clinical practice.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In the current context, it is advisable to review the possible barriers and risks for its appropriate implementation, together with a proposal for a classification that allows us to face and overcome its limitations, in order to maintain the quality of care and protect patient safety/security.</p><p id="par0010" class="elsevierStylePara elsevierViewall">From a historical point of view, remote medicine has been practised since the time of Galen (129-c.201/216), who answered medical consultations by epistolary means. In our more recent past― and with regard to video consultation―, as early as 1924, on the cover of its April issue entitled “The Radio Doctor”, the magazine Radio News<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> published the image of a child talking to a doctor via a screen, two years before television appeared. It was not until the 1950s and 1960s that the first experiments with telemedicine (teleconsultation) were carried out in the USA by the psychiatrist Cecil Wittson<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> using closed-circuit television. Later, in the 1970s, another American doctor, Thomas Bird, coined the term telemedicine from the Greek word “tele” and the Latin term “medicus” (“to cure at a distance”). In Spain, the first Telemedicine Unit<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> was created at the Hospital Central de la Defensa “Gomez Ulla” in 1996, and since then its use has increased exponentially. WHO established its definition of telemedicine in 1997; since then, medicine within the field of new technologies has progressively evolved to what we know today as Digital Health.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Generally speaking, although the published literature on barriers to telemedicine does not systematically show its limitations, it does describe the number of references<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a> to potential barriers within the articles included in systematic reviews. When analysing the possible limitations of telemedicine as a whole, 2 patterns can be observed that allow, in part, to differentiate the barriers from the risks; and to classify each of these into 2 subgroups. Barriers would include clinical/technological constraints, while risks would mainly involve aspects related to security and current legislation. While this is a classification where concepts can be intermingled and interchangeable, it provides a practical and simple approach to the implementation and practice of telemedicine.</p><p id="par0020" class="elsevierStylePara elsevierViewall">With regard to the limitations of telemedicine in daily clinical practice, the physical examination, the adaptation of the consultation to the patient's symptoms and characteristics, and the diagnosis are the priority elements. To address physical examination via telematics, possible alternatives have been developed with the aim of supporting the consultation, although so far it cannot be completely substituted. For this purpose, documents have been developed for self-examination<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> indicating how the patient can perform abdominal palpation or palpation of the pulses (radial and pedal). Moreover, the development of digital stethoscopes also allows automated recording and interpretation of cardiac and pulmonary auscultation, although they are still in the validation phase. With regard to imaging tests, ultrasound<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> is the technique that offers the most possibilities in terms of technique and methodology. Patient-performed and physician-interpreted imaging has been analysed, including studies using instant messaging applications. Finally, there is a wide range of FDA-approved smart devices such as wearables, vital signs monitoring and electrocardiograms that can be used remotely. The clinical context has been studied in relation to the symptoms and patient characteristics<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> that may be more appropriate for a teleconsultation, observing that certain symptoms such as dyspnoea, chest pain or abdominal pain are not considered appropriate for remote assessment by physicians. On the other hand, elderly patients, with psycho-functional limitations and on their first visit constitute groups that are difficult to manage through telemedicine and are at greater risk if there is no adequate support or equipment.</p><p id="par0025" class="elsevierStylePara elsevierViewall">With regard to diagnosis, the few studies conducted show an estimated concordance rate of 80%–85% in comparison with face-to-face consultations<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>; and according to the analysis by specialty, the diagnostic concordance rate in internal medicine is within this range.</p><p id="par0030" class="elsevierStylePara elsevierViewall">While there are currently possible solutions to the absence of physical examination in the non-face-to-face consultation, none of them have been shown to be useful in clinical studies. Both digital stethoscopes and ultrasound are likely to provide solutions in the near future, but the evidence is currently limited. Approved monitoring devices have not been shown to reduce potential events, as in the case of anticoagulation in patients with asymptomatic atrial fibrillation detected by these techniques; and those based on artificial intelligence, although approved, have limitations in determining their quality.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Other possible interferences in non-face-to-face care would include body language limitations (it is estimated that 50%–75% of communication is non-verbal), possible emotional and physical dehumanisation, different perception and experience, and excessive expectations and goals by both doctor and patient.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In order to be able to apply telemedicine, a relevant aspect is to determine the technological capacity and knowledge of the patient.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Not all the population has the same knowledge, which can lead to a situation of inequality. This inequality in access to new technologies and specifically to telemedicine is what is known as the digital divide.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a> The digital divide was included in the WHO report for sustainable development in point 10 (inequality in access), and subsequently in the report on the Digital Health Strategy 2021 drawn up by the Spanish Ministry of Health. Within the digital divide there are four main contexts where the divide is most evident: rural areas, elderly patients, unfavourable socio-economic conditions and gender.</p><p id="par0045" class="elsevierStylePara elsevierViewall">With regard to rural areas, the 2011 WHO report already indicated the need to implement telematic access to health professionals in rural areas. In Spain, the MINECO report in 2018 showed that the higher the speed of the Internet connection, the lower the population covered.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> In relation to older age and socio-economic conditions, several studies have shown that older patients and those with unfavourable socio-economic status have limited access to telemedicine. Excluded social groups also include migrants, mentally ill patients, prisoners, drug addicts, prostitution and ethnic factors as shown in the comparative study by Fernandez Da Silva et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> between the general population and social risk groups in Spain. With regard to gender differences, according to reports by the INE and the Ministry of Health, although the gap has been progressively decreasing between men and women― from 8:1 a few years ago to the current 2:1 ratio―, it is another relevant element to overcome in the digital divide.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Within security-related risks, their approach involves both technical aspects related to IT and legal aspects. In this sense, the protection of personal data in the chosen format (electronic, telephone, video, etc.) and the application of specific software,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> are key elements in reducing risks as far as possible. Cybersecurity-oriented protection measures are also included in the institutional priority actions, with the aim of preventing unauthorised access, maintaining the encryption of personal data and restoring availability and access.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> As the backbone of projects linked to new technologies, cybersecurity in Spain is carried out through active collaborations between the Ministry of Health and the National Cryptology Centre or the National Centre for the Protection of Critical Infrastructure.</p><p id="par0055" class="elsevierStylePara elsevierViewall">On the other hand, as general recommendations, it is advisable to avoid the use of social platforms and networks both because of the possible vulnerability in relation to privacy and data protection, as well as because of legal aspects that within the current framework may be controversial (consent and authorisation).</p><p id="par0060" class="elsevierStylePara elsevierViewall">Currently, there are no specific regulations governing telemedicine in Spain, and Spanish and European Union laws are applicable on a supplementary basis.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The article by Gil Membrado et al.,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> highlights the legal and ethical issues that remain to be addressed in relation to telemedicine, and which continue to be valid at the expense of the development of an adequate legislative framework adapted to its needs.</p><p id="par0070" class="elsevierStylePara elsevierViewall">With regard to the ethics and deontology of professional practice, the Spanish Central Commission of Deontology drafted a report in 2020 on telemedicine in the medical act, and in 2022 the World Medical Association issued a declaration on the ethics of telemedicine, with the aim of regulating and establishing bioethical recommendations on teleconsultation.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Another relevant aspect of legal risks, as in face-to-face clinical practice, is to avoid intrusion and to protect confidentiality; aspects also related and linked to security control.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Before considering a possible telemedicine consultation, it is advisable to first assess the patient's technological skills. The Cambados<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> questionnaire is one of the few tools available for this purpose, which identifies the patient with chronic illness and digital competences by means of a questionnaire of 20 questions distributed in 5 assessment blocks. This tool can estimate the chronic patient's ability to cope with a telematic consultation, as well as stratifying the patient according to their digital competences. Another relevant point, as previously mentioned, is the need for a physical examination of the patient. If needed, current options and techniques do not guarantee its replacement, and it is one of the main clinical barriers.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Ensuring decision-making capacity, privacy, consent and possible auditory or visual barriers by means of suitable equipment, multiple video-consultation or other alternatives are important conditions for a successful teleconsultation. In this regard, the SEMI Digital Medicine group has produced a simple and practical document on frequently asked questions and answers in telemedicine which can be accessed via the web: <a href="https://www.fesemi.org/grupos/medicina-digital/preguntas-telemedicina">https://www.fesemi.org/grupos/medicina-digital/preguntas-telemedicina</a>.</p><p id="par0090" class="elsevierStylePara elsevierViewall">A relevant aspect that biases access to telemedicine is the digital divide. To reduce it, a socio-political and technical approach is needed to improve living conditions, training and digital education. Certain social groups may be excluded and deprived of a tool that implies complementary access to the health system and medical care, thus altering the principles of equity and social justice.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Telemedicine is a useful and complementary tool to face-to-face consultation in clinical practice. Adequate individualisation for patient selection is key, but taking into account the digital divide and social groups that may be excluded and without access to new technologies. For quality clinical care, possible barriers should be taken into account, mainly involving clinical/technological aspects in connection with the patient, the doctor and the institution, as well as security and legal risks given the absence of specific legislation.</p><p id="par0100" class="elsevierStylePara elsevierViewall">As telemedicine is an efficient and applicable technology, the process of its implementation and progressive use as a new healthcare technology should be carried out according to the current paradigm of evidence-based medicine: in a judicious, conscious, clear way; with the application of the best available evidence and taking into account the patient's values and preferences.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no animal testing nor the use of patient data has been involved in the preparation of this article.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have received funding for this article.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest for this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Facilitators and Barriers to the adoption of telemedicine during the first year of COVID-19: systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. Kruse" 1 => "K. Heinemann" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "J Med Internet Res." "fecha" => "2022" "volumen" => "24" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Telemedicine in the United States: an introduction for students and residents" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.A. Hyder" 1 => "J. Razzak" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "J Med Internet Res." "fecha" => "2020" "volumen" => "22" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "El Sistema de Telemedicina Militar en España: una aproximación histórica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Hillán García" 1 => "F. Setién Dodero" 2 => "A. Del Real Colomo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Sanidad Militar." "fecha" => "2014" "volumen" => "70" "paginaInicial" => "121" "paginaFinal" => "131" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Barriers and facilitators that influence telemedicine-based, real-time, online consultation at patients’ homes: systematic literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H.K.Y. Almathami" 1 => "K.T. Win" 2 => "E. Vlahu-Gjorgievska" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "J Med Internet Res." "fecha" => "2020" "volumen" => "22" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Barriers and facilitators to the implementation of eHealth services: systematic literature analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "B. Schreiweis" 1 => "M. Pobiruchin" 2 => "V. Strotbaum" 3 => "J. Suleder" 4 => "M. Wiesner" 5 => "B. Bergh" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "J Med Internet Res." "fecha" => "2019" "volumen" => "21" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluating barriers to adopting telemedicine worldwide: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C. Scott Kruse" 1 => "P. Karem" 2 => "K. Shifflett" 3 => "L. Vegi" 4 => "K. Ravi" 5 => "M. Brooks" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/1357633X16674087" "Revista" => array:6 [ "tituloSerie" => "J Telemed Telecare." "fecha" => "2018" "volumen" => "24" "paginaInicial" => "4" "paginaFinal" => "12" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29320966" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The Telehealth ten: a guide for a patient-assisted virtual physical examination" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C.P. Benziger" 1 => "M.D. Huffman" 2 => "R.N. Sweis" 3 => "N.J. Stone" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjmed.2020.06.015" "Revista" => array:6 [ "tituloSerie" => "Am J Med." "fecha" => "2021" "volumen" => "134" "paginaInicial" => "48" "paginaFinal" => "51" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32687813" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ultrasound in telemedicine: a brief overview" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "F. Recker" 1 => "E. Höhne" 2 => "D. Damjanovic" 3 => "V.S. Schäfer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Appl Sci." "fecha" => "2022" "volumen" => "12" "paginaInicial" => "958" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Telehealth: the right care, at the right time, via the right medium" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Croymans" 1 => "I. Hurst" 2 => "M. Han" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.0564/1056/CAT.20" "Revista" => array:2 [ "tituloSerie" => "NEJM Catalyst." "fecha" => "2020" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnostic Accuracy of Telemedicine Utilized at Mayo Clinic Alix School of Medicine Study Group Investigators. Assessment of clinician diagnostic concordance with video telemedicine in the integrated multispecialty practice at mayo clinic during the beginning of COVID-19 pandemic from March to June 2020" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B.M. Demaerschalk" 1 => "A. Pines" 2 => "R. Butterfield" 3 => "J.M. Haglin" 4 => "T.C. Haddad" 5 => "J. Yiannias" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "JAMA Netw Open." "fecha" => "2022" "volumen" => "5" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A “not so quiet” revolution: systemic benefits and challenges of Telehealth in the context of COVID-19 in Quebec (Canada)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H. Alami" 1 => "P. Lehoux" 2 => "R. Attieh" 3 => "J.-P. Fortin" 4 => "R. Fleet" 5 => "M. Niang" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3389/fdgth.2021.721898" "Revista" => array:3 [ "tituloSerie" => "Front Digit Health." "fecha" => "2021" "volumen" => "3" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Exploring privilege in the digital divide: implications for theory, policy, and practice" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M.L. Fang" 1 => "S.L. Canham" 2 => "L. Battersby" 3 => "J. Sixsmith" 4 => "M. Wada" 5 => "A. Sixsmith" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/geront/gny037" "Revista" => array:6 [ "tituloSerie" => "Gerontologist." "fecha" => "2019" "volumen" => "59" "paginaInicial" => "e1" "paginaFinal" => "e15" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29750241" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Digital divide in perceived benefits of online health care and social welfare services: National Cross-Sectional Survey Study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "T. Heponiemi" 1 => "V. Jormanainen" 2 => "L. Leemann" 3 => "K. Manderbacka" 4 => "A.M. Aalto" 5 => "H. Hyppönen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "J Med Internet Res." "fecha" => "2020" "volumen" => "22" ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ICT-based public policies and depopulation in hollowed-out Spain: a survey analysis on the digital divide and citizen satisfaction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Pontones-Rosa" 1 => "R. Pérez-Morote" 2 => "J.F. Santos-Peñalver" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.techfore.2021.120811" "Revista" => array:3 [ "tituloSerie" => "Technol Forecast Soc Change." "fecha" => "2021" "volumen" => "169" ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "eHealth policy in Spain: a comparative study between general population and groups at risk of social exclusion in Spain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Á. Fernández Da Silva" 1 => "B.B. Buceta" 2 => "X.M. Mahou-Lago" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Digit Health." "fecha" => "2022" "volumen" => "8" ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Telemedicine, privacy, and information security in the age of COVID-19" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.S. Jalali" 1 => "A. Landman" 2 => "W.J. Gordon" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/jamia/ocaa310" "Revista" => array:6 [ "tituloSerie" => "J Am Med Inform Assoc." "fecha" => "2021" "volumen" => "28" "paginaInicial" => "671" "paginaFinal" => "672" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33325533" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hospital cybersecurity risks and gaps: review (for the non-cyber professional)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L. Wasserman" 1 => "Y. Wasserman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Front Digit Health." "fecha" => "2022" "volumen" => "4" ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Medical and legal aspects of the practice of teledermatology in Spain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "P.J. Gómez Arias" 1 => "E. Abad Arenas" 2 => "M.C. Arias Blanco" 3 => "J. Redondo Sánchez" 4 => "M. Galán Gutiérrez" 5 => "A.J. Vélez García-Nieto" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Actas Dermosifiliogr (Engl Ed)." "fecha" => "2021" "volumen" => "112" "paginaInicial" => "127" "paginaFinal" => "133" ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Telemedicina, ética y derecho en tiempos de COVID-19. Una mirada hacia el futuro" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Gil Membrado" 1 => "V. Barrios" 2 => "J. Cosín-Sales" 3 => "J.M. Gámez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rceng.2021.03.002" "Revista" => array:6 [ "tituloSerie" => "Rev Clin Esp." "fecha" => "2021" "volumen" => "221" "paginaInicial" => "408" "paginaFinal" => "410" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/34034965" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "E-young chronics y e-senior chronics como nuevos modelos para la atención a la cronicidad" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Martínez-Pillado" 1 => "I. Said-Criado" 2 => "A. Regueiro-Martínez" 3 => "I.C. Rodríguez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jhqr.2018.07.001" "Revista" => array:6 [ "tituloSerie" => "J Healthc Qual Res." "fecha" => "2018" "volumen" => "33" "paginaInicial" => "119" "paginaFinal" => "120" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30328812" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000016200000003/v2_202402160843/S2387020624000111/v2_202402160843/en/main.assets" "Apartado" => array:4 [ "identificador" => "46797" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorial article" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000016200000003/v2_202402160843/S2387020624000111/v2_202402160843/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020624000111?idApp=UINPBA00004N" ]
