Scoping Review of Pulmonary Telemedicine Consults: Current Knowledge and Research Gaps

Abstract

Rationale

Telemedicine consults, including video consults, telephone consults, electronic consults, and virtual conferences, may be particularly valuable in the management of chronic pulmonary diseases, but there is limited guidance on best practices for pulmonary telemedicine consults.

Objectives

This scoping review aims to identify, characterize, and analyze gaps in the published literature on telemedicine consults health providers use to manage patients with chronic pulmonary diseases.

Methods

We searched PubMed, Embase, Web of Science, and Cochrane Library from database origin through July 10, 2021. We included manuscripts describing applications of telemedicine consults for patients with chronic pulmonary diseases (asthma, chronic obstructive pulmonary disease, lung cancer, pulmonary hypertension, and interstitial lung disease). We restricted our review to full-length articles published in English about provider-led (as opposed to nurse-led) telemedicine consults.

Results

Our search yielded 3,118 unique articles; 27 articles met the inclusion criteria. All telemedicine consult modalities and chronic pulmonary conditions were well represented in the review except for pulmonary hypertension and interstitial lung disease, which were represented by one and no articles, respectively. Most articles described a small, single-center, observational study that focused on the acceptability, feasibility, use, and/or clinical effectiveness of the telemedicine consult. Few studies had objectively measured clinical outcomes or included a comparator group, and none compared telemedicine consult modalities against one another.

Conclusions

Our scoping review identified limited literature describing pulmonary telemedicine consults and highlighted several gaps in the literature that warrant increased attention. Providers treating chronic pulmonary diseases are left with limited guidance on best practices for telemedicine consults.

Telemedicine is rapidly increasing, with the proportion of U.S. hospitals offering telemedicine rising from 35% in 2010 to 76% in 2017 (1) and substantial further increases in telemedicine use occurring in response to the coronavirus disease (COVID-19) pandemic (2–4). Many telemedicine services are designed to substitute for traditional, in-person appointments. We have labeled these as telemedicine consults, which include video and telephone calls between providers and patients, virtual conferences between providers, and e-consults between providers. For patients, telemedicine consults can be more convenient than traditional in-person visits, reducing travel times and improving the timeliness of care (5). For providers, telemedicine consults can increase flexibility, improve efficiency, and lower rates of burnout (6, 7). During the COVID-19 pandemic, reimbursement for telemedicine services improved (8, 9), allowing these consults to play a central role in delivering safe and timely medical care (10, 11).

Telemedicine consults may be particularly valuable in the management of chronic pulmonary diseases. These patients often have a high symptom burden, limiting their ability to travel for appointments (8, 9). Telemedicine consults could improve patient follow-up and treatment adherence in this population, especially at sites in which pulmonary expertise is lacking (12–14). Pulmonary telemedicine consults have become more important during the COVID-19 pandemic as they allow high-risk patients to mitigate the risk of infection when seeking care.

Despite potential advantages, there is limited research describing the appropriate use of pulmonary telemedicine consults. Most of the existing telemedicine research in pulmonary disease has focused on other telemedicine applications, particularly remote patient monitoring and mobile app integration. Increased attention is needed to document how pulmonary telemedicine consults have been successfully applied in real-world settings. The objective of this scoping review is to identify, characterize, and analyze gaps in the published literature on telemedicine consults for chronic pulmonary diseases. This information will help map the body of literature on pulmonary telemedicine consults, provide a launching point for future research, and help inform future efforts to establish guidelines on best practices for pulmonary telemedicine consults.

Methods

Search Strategy and Definitions

Our search strategy involved several steps: 1) simultaneous searches of MEDLINE via PubMed, Embase, Web of Science, and Cochrane Library electronic databases; and 2) manual searches of reference lists from included articles to capture studies that did not register in the electronic search. We developed search terms with the help of an experienced medical librarian (15). The full electronic search strategy for PubMed is presented in the data supplement.

Database searches focused on telemedicine consults for chronic pulmonary conditions. We defined telemedicine consults as 1) synchronous video and/or telephone consults between providers and patients; 2) synchronous video and/or telephone conferencing between providers; and 3) asynchronous e-consults between providers. We defined chronic pulmonary conditions to be consistent with the World Health Organization definition: asthma, chronic obstructive pulmonary disease (COPD), lung cancer, pulmonary hypertension, and interstitial lung disease (16, 17). We focused on pulmonary telemedicine consults engaged by providers, which we defined as physicians, physician assistants, or nurse practitioners.

We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews checklist (18) and the JBI Manual for Evidence Synthesis on Scoping Reviews (19). We used publicly available data, and Institutional Review Board approval was not required.

Eligibility Criteria, Selection of Studies, and Data Extraction

We included published peer-reviewed articles that satisfied all eligibility criteria: 1) described the application of a pulmonary telemedicine consult; 2) included consults that were administered by providers (as opposed to nurses); and 3) were full-length articles published in English between database inception and July 10, 2021. We excluded opinions, perspective pieces, and studies that described telemedicine consults as a smaller subset of the overall study (e.g., telemonitoring programs that triggered telemedicine consults for observed abnormalities) unless they reported separate outcomes specific to pulmonary telemedicine consults.

Three independent reviewers (B.L., B.M.-P., and S.T.R.) screened titles and abstracts for eligibility using Rayyan screening software (20), with each article evaluated by two reviewers. Reviewers were blinded to each other’s decisions. Disagreements were resolved by discussion or a third reviewer if a consensus could not be reached. Reviewers engaged in regular meetings to clarify issues and questions about inclusion criteria. Articles that met inclusion criteria after title/abstract screening were reviewed in full by one reviewer (B.L., B.M.-P., K.R.G., or S.T.R.).

From included studies, we extracted the following: title, publication year, author(s), journal, country, type of telemedicine consult, provider type, participant characteristics and sample size, study period, aims, study design, methods, relevant outcomes, and conclusions.

Results

The initial electronic search yielded 3,118 unique articles. After the title/abstract and full-length article screening, 27 articles were included in the review (see data supplement). The most common reasons for exclusion were that a telemedicine consult program was not described, the article was the wrong publication type (e.g., conference abstract), and the article was not related to pulmonology. Manual searches of reference lists of included articles yielded no new articles that satisfied the inclusion criteria.

Characteristics of Included Studies

The 27 included studies encompassed 15,132 patients and 248 providers. Most were small, single-center studies describing a telemedicine consult program. Study outcomes tended to focus on the acceptability, feasibility, use, and clinical effectiveness of the telemedicine consult. Most studies were observational (n = 24); one study used a randomized controlled trial design (21), one used a crossover experimental approach (22), and two used a quasi-experimental design (23, 24). Only nine studies were conducted in the United States, most of which used small samples, collectively totaling 737 patients. Five studies included a comparator group, and three studies compared outcomes before versus after intervention. Most studies were quantitative (n = 26), and one was qualitative. An overview of the telemedicine modalities, disease types, and publication dates of the studies is included (Table 1), together with a high-level summary of the results (Figure 1). Detailed information on these studies is included in Table 2 and the following text.

Table 1.

Characteristics of identified articles

Modality	n
Synchronous, provider-to-patient video/telephone consults	17
Video consult only	10
Telephone consult only	5
Both	2
Synchronous, provider-to-provider virtual conference	4
Asynchronous, provider-to-provider, e-consultation	5
Other	1
Disease type
Asthma	5
COPD	4
Lung cancer	6
Pulmonary hypertension	1
Interstitial lung disease	0
Multiple chronic pulmonary diseases	11
Publication years
1998–2003	2
2004–2009	6
2010–2015	8
2016–2021	11

Definition of abbreviation: COPD = chronic obstructive pulmonary disease.

Figure 1.

Summary of results.

Table 2.

Summary of included articles

Source	Setting	Study Population	Study Design	Major Findings
Video consults
Bian et al. (24)	United States; population study of five counties in South Carolina (one implemented school-based asthma telemedicine in all public schools).	A total of 215,118 asthma child-months of observation, including 21,934 child-months in telemedicine county of interest.	Quasi-experimental design with difference-in-difference analysis using county-level Medicaid claims of pediatric emergency department visits.	School-based, asthma telemedicine improved access to underserved communities and effectively reduced emergency department visits in the county that implemented school-based telemedicine programs when compared with other counties.
Raza et al. (28)	United States; multisite study at two Veterans Affairs medical centers in Wisconsin and Michigan.	A total of 314 veterans with pulmonary video consults, totaling 684 consults made from a remote medical center to a tertiary care center.	Retrospective chart review study of video consults with reasons for referral, the medical process of care, medical decision-making, and access to care, as well as patient satisfaction surveys.	The most common reasons for consultation were abnormal radiology (38%), COPD (26%), and dyspnea (13%). Video consults were reliable, cost-effective, and associated with high patient satisfaction. They improved patient access to specialty care and allowed patients to receive medical care at the satellite hospital, reducing the need for the transfer of care. Pulmonary physicians made clinically significant management changes for almost half of the patients, demonstrating telemedicine can be effective.
Portnoy et al. (25)	United States; single-site study at an academic pediatric hospital in Missouri.	A total of 169 children with asthma.	Quasi-experimental design of video vs. in-person consults outcomes, using asthma symptom assessment and satisfaction surveys. Telemedicine used technology that included a digital stethoscope, otoscope, and high-resolution camera.	Video consults were as effective as in-person visits in managing asthma symptoms and had high degrees of patient satisfaction.
Bergman et al. (27)	United States; multisite study at three elementary schools in San Francisco.	A total of 96 children with asthma not under the care of an allergist or pulmonologist.	Uncontrolled pre–post study of feasibility, acceptance, and effectiveness of a school-based telemedicine program.	The program was feasible, improved specialist efficiency, and effectively provided diagnosis, education, and appropriate asthma management.
Pacht et al. (22)	United States; Ohio Department of Rehabilitation and Corrections.	A total of 40 patients managed in the pulmonary clinic.	Crossover trial by two pulmonologists who sequentially examined patients by video vs. in-person consults. Two separate pulmonologists compared the results of history, exam, evaluation, and treatment plans.	The ability to obtain an accurate history, perform a physical examination (including lung auscultation), formulate a diagnostic impression, and devise a treatment plan was just as effective with video consults as in-person consults. Patients were also generally satisfied with video consults.
Agha et al. (32)	United States; multisite study at two Veterans Affairs medical centers in Wisconsin and Michigan.	A total of 19 veterans referred for pulmonary medicine consultations from a remote medical center to a tertiary care center, including 11 video consults and 8 in-person consults.	Analysis of recorded video consults using the roter interaction analysis system (RIAS) to compare verbal and nonverbal physician–patient communication during video consultation vs. in-person appointments.	Physicians were more likely to dominate the conversation in video consults, resulting in a “physician-centered” communication style. Patients were less engaged and more passive during these video consults, and more time was spent discussing biomedical topics and less time on psychosocial and lifestyle issues.
Pardolesi et al. (29)	Italy; single-site study at an academic clinic.	A total of 83 patients with thoracic surgery consultations.	Survey study of patient satisfaction and acceptability of video consults.	More than 95% of participants rated being very satisfied with communication, effectiveness, organization, and technology.
Emme et al. (21)	Denmark; multisite at two academic hospitals in Copenhagen.	A total of 52 patients with GOLD stage III–IV COPD who presented to the emergency department with acute COPD exacerbation.	Nonblinded randomized clinical trial of virtual vs. conventional hospital admission.	There were no significant differences in patient self-efficacy between virtual vs. conventional hospital admission at 3 d, 6 wk, or 3 mo after discharge.
Mantzouranis (31)	Greece; single-site study at an academic institute.	A total of 10 children with asthma.	Observational study of several telemedicine appointments with patient and provider surveys.	Telemedicine consults were accepted by all patients and 90% of patients’ parents. Many experienced technical problems, the most serious being network instability. Patient and physician satisfaction was associated with connection quality.
Telephone consults
Raju et al. (34)	United States	A total of 48 adult patients with asthma.	Prospective cohort study of monthly telephone consults that were repeated for up to 5 mo or until asthma was controlled. Data were mainly collected on when asthma became controlled.	Asthma was effectively managed through telephone consults. Asthma control improved from 69% of patients to 83% during the study period.
Kumari et al. (35)	India; single-site study at an academic clinic.	A total of 188 children, of which 58% had asthma. The study also included patients’ caregivers (n = 121) and associated resident physicians (n = 5).	Ambispective observational study of telephone consults with retrospective chart review and prospective patient/caregiver and provider surveys.	Most children with respiratory illnesses were successfully managed via telephone consult, although 5% were recommended for an in-person visit. Although 80% of caregivers were satisfied with telephone consults, only half would want to continue after the COVID-19 pandemic. There were few technical difficulties. Physicians indicated they prefer video consults over telephone consults.
Vijayakumar et al. (69)	Netherlands	A total of 111 patients referred by local general practitioners because of suspicion of lung malignancy.	Survey study of responses from patients who received a telephone consult.	Results showed high satisfaction with the telephone consults.
O’Byrne et al. (36)	United Kingdom; single-site study at an academic clinic.	A total of 106 patients referred to respiratory clinics. Most (60%) had breathlessness, chest pain, cough, or obstructive disorder.	Cohort study comparing clinic volume and patient satisfaction among telemedicine, nontelemedicine, and nonparticipant groups.	Preclinic telephone consults reduced in-person visits, improved patient compliance, and did not impact patient satisfaction.
Roberts and Partridge (37)	United Kingdom; multisite study at three respiratory clinics.	A total of 104 patients with respiratory disease who had longitudinal clinic follow-up.	Uncontrolled pre–post study of timing, duration, and satisfaction of telephone vs. in-person consults. All patients first received a telephone consult and then an in-person consult.	When compared with in-person consults, telephone consults were more likely to start on time and had a shorter consult duration. There was no difference in patient satisfaction. However, there was greater nonattendance for telephone consultations, and not all phone numbers were functional.
Serena et al. (33)	Switzerland; single-site study at an academic hospital.	A total of 46 patients with non-small cell lung carcinoma (94%) or small cell lung carcinoma (6%).	Chart review and patient survey study of telephone consult program (outcome available for only 56% of patients).	Telephone consults were feasible and effective for collecting patient-reported outcome measures. A total of 76% completed all telephone consults. Self-efficacy with managing lung cancer and treatment-related symptoms improved, although symptom intensity increased.
E-consults
Wrenn et al. (45)	United States; multisite study at eight academic primary care clinics.	A total of 200 e-consults, 14 of which were to pulmonary medicine.	A retrospective study of e-consult requests and responses.	Most e-consults (11/14) were related to diagnosis; fewer focused on treatment (3/14).
Metting et al. (70)	Netherlands; multisite study.	A total of 11,401 patients referred for respiratory consultation.	Cross-sectional baseline study with longitudinal results of e-consult program. Data were collected on clinical assessments (e.g., assessment of airflow obstruction, inhalation technique, and symptoms management) and feasibility factors.	E-consults for asthma and COPD were effective and feasible. Patients’ inhalation technique improved, the proportion of patients with well-controlled asthma and COPD increased, and asthma and COPD exacerbations decreased. About 2,000 new patients could be assessed yearly, and 79% of patients could be diagnosed.
Thijssing et al. (44)	Netherlands; multi-site study.	A total of 4,488 pulmonary e-consults sent by 342 generalists to 43 pulmonologists.	Retrospective review of e-consults, including provider satisfaction survey.	A total of 955 e-consults were sent, and 565 (59%) were effectively addressed via e-consult, averting in-person appointments. In 72% of the consults, generalists indicated they were helped by the response, and 68% indicated that they learned from it.
Thijssing et al. (42)	Netherlands; multisite study.	A total of 309 pulmonary e-consults sent by 158 general practitioners.	Retrospective chart review of e-consult content.	E-consults prevented unnecessary in-person appointments for 68% of consult requests. Most general practitioners indicated that e-consults were educational (92%) and felt that they improved care (96%).
Malone et al. (43)	Guam, South Korea, Japan; multisite study of three health systems.	Seven children with moderate to severe asthma managed through an e-consult program.	Longitudinal observational study over 1 yr, including healthcare use, spirometry, symptom change, and physician experience.	E-consults resulted in decreased urgent care and emergency department visits, and patients reported improved symptoms. There was no change in spirometry outcomes. Primary care providers’ self-reported ability to manage asthma improved.
Virtual conferences
Stevenson et al. (40)	United States; multisite study at academic and affiliated hospitals.	A total of 37 patients presented at virtual conferences and 20 tumor board participants.	Observational study of virtual conference proceedings, including a narrative summary of proceedings and survey of conference attendees.	The virtual tumor board improved accessibility and convenience and shortened the time for patients to receive a definitive treatment plan. A total of 40% preferred the virtual format, 40% were neutral, and 20% preferred the in-person format. 70% planned on continuing to attend.
Seeber et al. (39)	Italy and Austria; multisite study at three hospitals.	A total of 203 patients with any lung cancer; 90% were stage III or IV.	Retrospective chart analysis of lung cancer patients who were vs. were not presented at a virtual conference.	Tumor video conferencing was feasible for most patients and facilitated access to treatment that was available only at the cancer center (radiotherapy was prescribed significantly more frequently for patients presented in the tumor conference than for those not presented [70% vs. 30%]).
Takeda et al. (38)	Japan; multisite study at eight general hospitals.	A total of 202 patients with lung cancer.	Retrospective review of tumor board proceedings and changes in diagnostic or treatment plans.	A web-based tumor board using shared desktop technology was both secure and feasible. The tumor board was more accessible and more efficient than previous in-person conferences between multiple hospitals. There were challenges with ensuring adequate infrastructure and technical support. The tumor board changed care plans for 49 patients.
Duplaga et al. (41)	Poland; multisite study including an academic hospital and other consulting hospitals.	A total of 41 patients with pulmonary consults. The most common issues included suspected malignant lung or pleural process, occult forms of tuberculosis, and suspected atypical mycobacterial infection.	Retrospective review of virtual conference consultations to pulmonary specialists at a regional academic hospital.	Most consults were appropriate for telemedicine; 41.5% of patients were selected for further diagnostic procedures in an ambulatory setting; 29.3% were admitted for interventional pulmonology; 12.3% were referred for thoracic surgery; 17.1% remained in the peripheral center.
Other
Sabina Sousa et al. (30)	Portugal	A total of 55 patients with asthma who had participated in a telephone or video consult.	A survey study of telemedicine consults occurring during the COVID-19 pandemic.	Patients who were satisfied with telemedicine consults indicated that communication between patients and providers was not compromised. However, one-half of patients ranked their last telemedicine visit to be inferior to in-person consults.
Tamura et al. (26)	Japan; single-site study at an academic hospital.	A total of 40 patients with a diagnosis of pulmonary hypertension.	A survey study of telemedicine consults occurring during the COVID-19 pandemic.	Patients indicated that internet-based video consults were useful, especially for patients who needed advanced care. However, some older patients had a difficult time adjusting to new technology and preferred telephone consultations.
Gaveikaite et al. (46)	Greece	Four healthcare workers, including a pulmonologist, a pulmonologist in training, a physiotherapist, and a nurse.	A qualitative study of providers’ perceptions of COPD telemedicine consults.	Respondents described opportunities for telemedicine to improve care by providing education, promoting medication adherence, encouraging physical activity, supporting treatment for tobacco dependence, and managing comorbidities. Respondents also noted the importance of addressing technical and structural elements of telemedicine consults.

Definition of abbreviations: COPD = chronic obstructive pulmonary disease; COVID-19 = coronavirus disease; GOLD = Global Initiative for Chronic Obstructive Lung Disease.

Studies on Provider–Patient Video Consults

General description

Studies describing provider–patient video consults evaluated instances in which patients spoke directly to providers during a consult using video technology. Some studies used the patient’s personal electronic device, and others allowed patients to travel to a nearby facility equipped with remote video conferencing technology, which was sometimes staffed with a nurse or technician to assist with physical examination and use of the technology.

Strengths

In general, video consults had positive impacts on clinical outcomes for patients, including decreased emergency department visits and more guideline-concordant care compared with those not enrolled in the video telemedicine program and as-effective symptoms management compared with in-person visits (24–28). Most patients participating in these consults had high satisfaction (22, 25, 29, 30) and found them more convenient than in-person appointments (28). Providers indicated that video consults enabled them to work more efficiently (28).

Challenges

Two studies reported difficulties using video-based technology for patients and providers (26, 31). Despite mostly high patient satisfaction, one study found mixed patient experiences, with some disliking their video consult (30). In addition, one study suggested that video consults were less patient-centered, as providers dominated the dialogue compared with in-person appointments (32).

Studies on Provider–Patient Telephone Consults

General description

Studies describing provider-patient telephone consults evaluated instances in which patients spoke directly to providers over the phone. Telephone consults were used in various ways, including before the first in-person appointment to take a brief history and guide initial testing, after an in-person appointment as a follow-up, or as a substitute for an in-person appointment.

Strengths

These consults were associated with increased self-efficacy for managing symptoms and improved asthma control (33, 34). They were also found to be more convenient for patients and their caregivers because they eliminated travel, were more likely to start on time, and led to similar satisfaction compared with in-person appointments (30, 33, 35, 36).

Challenges

Studies reported mixed results regarding patient participation. One study found greater nonattendance for telephone consults compared with usual care (37), whereas another found high adherence rates to scheduled telephone consults (33). Within studies, some providers ran into technical issues when trying to establish a connection and others reported no problems at all (35, 37).

Studies on Provider–Provider Virtual Conferences

General description

All four studies describing virtual conferences between multiple healthcare providers investigated conferences that had the purpose of aiding rural or satellite medical centers by sharing knowledge and resources from larger medical centers. Most of these studies focused on managing patients with lung cancer (38–41).

Strengths

Virtual conferences between providers were secure, feasible, and more accessible and efficient when compared with in-person conferences (38). One study examining clinical outcomes found that virtual conferences led to changes in therapeutic strategies in 24% of presented patients (38). Providers found these conferences helpful for patient care (39, 40).

Challenges

Two studies noted that these conferences required robust infrastructure and technical support for secure connections (38, 40). One study found that conferences initially had low participation, which increased after greater leadership engagement. Another study found that an obstacle to participation was the fear of revealing existing practices at smaller hospitals (41).

Studies on Provider–Provider E-consults

General description

Five studies reported on the use of e-consults by primary care providers (PCPs) to seek pulmonary specialist input without relying on a patient appointment with the specialist.

Strengths

In general, e-consults had positive outcomes and were well-received by PCPs. E-consults improved provider disease management (42–44), reduced disease exacerbations (45), and decreased in-person referrals (42–44). PCPs also had high satisfaction with this approach, in part because they felt that e-consults were educational and improved their own self-efficacy (42–44).

Challenges

The approach to requesting e-consults is still evolving. Pulmonologists tend to prefer a structured, algorithm-based e-consult form, whereas PCPs do not (43). When PCPs were forced to use the structured algorithm, they were less enthusiastic about e-consults.

All Telemedicine Consults

A qualitative study investigated perceptions of all aspects of pulmonary telemedicine consults through semistructured interviews with providers who cared for patients with COPD (46). Respondents indicated that telemedicine consults addressed several care delivery gaps for patients with COPD, including patient education, medication adherence, physical activity promotion, treatment for tobacco dependence, and comorbidity management.

Discussion

In this scoping review, we describe the state of the literature on pulmonary telemedicine consults, which includes relatively few published studies. Studies tended to be small, single-site, observational studies that described a narrowly focused telemedicine program, and very few used pragmatic or randomized trial designs. Most telemedicine programs focused on asthma, COPD, and lung cancer management, with only one article focusing on pulmonary hypertension and none on interstitial lung disease. Only 9 of the 27 studies were in the United States. Yet, even in this limited literature, we found diverse telemedicine consult modalities that incorporated different technologies to provide virtual care.

Our review highlighted important lessons learned from prior research. All studies highlighted key strengths of pulmonary telemedicine consults, with many describing improved efficiency, timeliness, and access to care, while also maintaining high degrees of patient and provider satisfaction. There were also notable challenges, especially related to technology use, that were more apparent for telemedicine consults that used more advanced technology (e.g., video visits) and those that engaged multiple parties (e.g., virtual conferences). No studies compared different telemedicine modalities, and insufficient evidence exists to guide the appropriate use of this approach to care delivery.

Although research on pulmonary telemedicine consults is still nascent, other specialties have a longstanding history of integrating telemedicine consults as a key tool in their armamentarium (47). Psychiatry has incorporated telephone and videoconferencing since the 1950s, and there are robust studies, including numerous randomized trials, that have shaped guidelines on appropriate telemedicine use for diverse mental health conditions (48–52). Dermatologists have effectively used photography and videoconferencing to diagnose and treat dermatological conditions, and relevant teledermatology guidelines are available (53). Likewise, cardiology, hematology, and nephrology have broad literature bases examining telemedicine consults, offering specific recommendations for clinicians (54–56). In contrast, pulmonary telemedicine consults are still an emerging field. Future research can draw on lessons, ideas, and best practice guidelines from existing telemedicine research in other specialties to inform appropriate use guidelines for pulmonary telemedicine consults (57–60). A recent perspective article highlights several potential guiding principles, including that telemedicine consults should: 1) achieve comparable safety and effectiveness as traditional care; 2) achieve a net increase in efficiency and cost-effectiveness; and 3) be respectful of patient preferences and values and not exacerbate healthcare disparities (60).

Our scoping review highlights notable research gaps that could inform future work (Figure 2). There are few published trials on the effectiveness of pulmonary telemedicine consults; none of these compared the clinical outcomes of one telemedicine consult approach to another, and few directly measured objective outcomes. Existing literature has also not incorporated mixed-methods implementation science methodology. Hybrid implementation–effectiveness trials could advance the field and offer specific guidance on how to best integrate telemedicine consults into existing pulmonary practice (61). As the knowledge base grows, consensus methods could engage experts to determine the appropriate application of pulmonary telemedicine consults, important organizational and technological characteristics of these programs, and implementation strategies that could support this telemedicine consult use.

Figure 2.

Summary of areas for future research.

Further research is needed to address patient- and disease-specific factors that may influence appropriate telemedicine consult use. Most studies in our review focused on asthma, COPD, and lung cancer but did not attempt to delineate when different types of telemedicine consults versus in-person appointments are warranted. Research is needed to explore the role of telemedicine consults in initial versus follow-up appointments, for diagnosis versus management decisions, for patients with mild versus severe disease, and how patient preference should factor into decisions related to the choice of care modality. For pulmonary medicine, in particular, it will be important to understand when common tests like spirometry (62) and 6-minute-walk tests (63) can be assessed via telemedicine consult and when patients need to present for a physical exam, imaging, or pulmonary procedures. Further research is also needed to assess unique opportunities for managing less common pulmonary diseases.

Finally, major gaps exist in understanding essential organizational and technology elements of successful pulmonary telemedicine programs. Research is needed to identify training, infrastructure, and support that may be needed for various types of telemedicine consults. One of the most common challenges noted in our review was technical difficulties, especially for patients and providers unfamiliar with telemedicine technology (64, 65). Disparities in technology and internet access require special attention to ensure that telemedicine care is safe and equitable (66–68). Pulmonary telemedicine appointments may also lead to missed opportunities for vaccination, an issue that must be addressed. Few studies have examined pulmonary telemedicine programs in the United States, and additional research is needed to explore policies, contextual factors, and cultural elements that support successful telemedicine efforts in different health systems. This research should assess the effects of billing and reimbursement and describe how telemedicine consults evolve over time.

Despite notable gaps in the literature, the available evidence offers a compelling case for embracing pulmonary telemedicine consults and supporting future research. Several highlight the value of telemedicine consults in improving timeliness, efficiency, and access to care (28, 36, 39, 42). Pulmonary specialty care is a limited resource, with current projections indicating a major shortage of pulmonary physicians in the coming years (14). Articles in our review also note widespread patient and provider satisfaction with pulmonary telemedicine consults (22, 25, 29, 30, 33, 35, 36, 42–44), although there were concerns that telemedicine consults could disrupt the provider–patient relationship (32). As telemedicine consult use expands, it is imperative that we identify and encourage norms and behaviors that apply principles of positive communication and reinforce interpersonal relationships.

Limitations

There are limitations to this scoping review. First, although our search used four independent reference databases, we may have overlooked some published studies. Second, we only focused on select respiratory conditions. Third, we excluded nurse-led telemedicine consults; additional research is needed to explore the role of provider versus nurse-led telemedicine programs. Lastly, the language used to describe telemedicine consults was vast and inconsistent, which may have led to missed studies during the search. We attempted to cast a broad net with a comprehensive set of search terms to prevent missing studies (see data supplement).

Conclusions

Our scoping review revealed limited literature describing pulmonary telemedicine consults. Many of the published reports are on the basis of small, single-site, observational studies, and there are several gaps in the literature. Providers treating chronic pulmonary diseases are left with limited guidance on the best practices for telemedicine consults. Given the notable promise of telemedicine consults to improve timeliness, quality, efficiency, and access to care, researchers and institutions should invest in high-quality studies to strengthen current knowledge, address existing gaps, and further delineate the benefits of and potential challenges with pulmonary telemedicine consults.