Telemedicine and eHealth Solutions in Clinical Practice

Introduction: Over the past decade, telemedicine and mobile health have experienced significant growth, becoming essential tools for healthcare in an increasingly digitized world. This research focuses on exploring how these technologies have improved the accessibility, efficiency and quality of healthcare, despite challenges related to data security and equity of access, with the aim of understanding their impact and potential in modern healthcare. Methods: a PubMed search was performed using the keywords "Telemedicine" and "mHealth" to find relevant studies on its application in clinical practice, with inclusion criteria covering articles in Spanish and English published between 2018 and 2023, freely available. The PRISMA workflow was followed to review and synthesize key findings and trends in this field. Result: the contribution of countries such as China, Australia and the United States in telemedicine and mobile health, with a focus on cardiovascular diseases and metabolic disorders, is highlighted. The positive impact on chronic diseases, mental health, physical activity and treatment adherence is highlighted, but the need to adapt interventions and lack of COVID-19 studies is emphasized. Conclusions: Telemedicine addresses a variety of pathologies, focusing on chronic diseases, with China leading in contributions. eHealth seeks to improve health outcomes and reduce the burden of disease.


INTRODUCTION
In the last decade and more recently, in the wake of the coronavirus pandemic, telemedicine and mobile health have experienced significant growth and radical transformation 1 .In an increasingly interconnected, digitized and technology-dependent world, medicine is bursting to make use of these advances 2 3 4 5 .Today they have become essential tools for healthcare delivery and health management in contemporary society 6 7 8 9 .
Telemedicine is a modality of medical care that involves the use of electronic communication technologies to enable the evaluation, diagnosis, treatment and follow-up of patients at a distance 10 11 .In other words, it involves the delivery of health care services without physicians and patients necessarily being in the same physical location.Telemedicine uses a variety of tools, such as videoconferencing, mobile applications, online medical data exchange and remote monitoring devices, to facilitate interaction between healthcare professionals and patients, providing access to medical care in remote locations or in situations where face-to-face consultation is not possible 12 13 .
It can be said that twenty years ago medical care was rooted in the model of face-to-face consultation in hospitals and doctors' offices 14 15 .However, with the evolution of information and communications technology, telemedicine has emerged as an innovative approach that allows patients and healthcare professionals to connect through electronic means, social networks and other virtual environment 16 , with its pro and cons 17 18 19 20 21 22 .This has revolutionized the way healthcare is delivered by making it more accessible and convenient, although there are many gaps still 23 24 25 .Now, people can consult their doctors, receive diagnoses and treatments, and even manage their chronic illnesses from the comfort of their homes using electronic devices, such as computers, smartphones and tablets 26 27 .Simultaneously, mobile health or eHealth has gained importance as mobile devices have become ubiquitous in everyday life.Health apps, health tracking devices and wearable medical sensors allow individuals to monitor their well-being continuously and take preventative measures to stay healthy.In addition, these technologies also allow physicians to access real-time information about their patients, facilitating more informed medical and administrative or educational decision-making 28 29 30 31 .Mobile health, or eHealth, refers to the use of mobile devices, such as smartphones and tablets, along with specific software applications, to provide healthcare services, health monitoring and wellness promotion 32 .This technology enables individuals to access health information, track their biomedical data, receive reminders and health tips, and communicate with healthcare professionals through applications designed for these purposes.In addition, eHealth can also involve wearable devices, such as smartwatches and health sensors, which collect vital data and transmit it to mobile applications for analysis and continuous monitoring 33 .In a world where geographic distance is no longer an insurmountable barrier and where medical information is within reach, telemedicine and mobile health are transforming medical care by making it more efficient, accessible and personalized 34 35 .These technologies have not only revolutionized the relationship between physicians and patients, but have also opened up new possibilities in the management of public health, the care of remote populations and the improvement of the quality of life of people around the world 36 .In this context, it is essential to explore in detail the key aspects of telemedicine and mobile health to understand their impact and potential in the field of modern healthcare 37 38 .
Despite the obvious benefits such as remote care, cost reduction and convenience and flexibility, this modality of care presents challenges such as safeguarding and securing patients' clinical data, achieving equity in access, among others.It is important to address these challenges in order to maximize the benefits of telemedicine and mobile health, while ensuring the quality and safety of medical care provided through these technologies.The central objective of this research focuses on exploring the validated uses and effective applications of telemedicine and mobile health solutions in the clinical practice setting.It seeks to comprehensively understand how these technologies have evolved to contribute significantly to improved medical care and patient outcomes.To this end, we will investigate how these technological tools have impacted the accessibility of medical services, optimized the efficiency of care, and elevated the quality of medical care provided in today's healthcare context.

METHOD
To carry out the literature search related to telemedicine and eHealth solutions used in clinical practice, a search was performed in PubMed.The keywords used in this search were "Telemedicine" and "mHealth".The search term used was: Telemedicine AND "mHealth".This methodology was designed similar to previous studies regarding comparable objectives 39 40 41 42 43 .To ensure the selection of relevant studies, both inclusion and exclusion criteria were established.Studies should focus on the application of telemedicine and mobile health solutions in clinical practice.Meta-analysis articles in Spanish and English between 2018 and 2023 were taken.Studies had to be openly and freely available.Titles and abstracts of articles identified in the initial search will be reviewed to determine their relevance to the article topic.Articles that meet the inclusion criteria will be reviewed in their entirety to extract relevant information about the application of telemedicine and mobile health solutions in clinical practice, as well as the associated benefits and challenges.An analysis and synthesis of the results of the selected articles will be conducted, highlighting key findings and trends in the implementation of telemedicine and mobile health in clinical practice.The review was carried out following the PRISMA workflow detailed in Figure 1 detailed in figure 1 44 .

RESULTS
Technological advances have radically transformed the way healthcare is delivered around the world.They have emerged as powerful tools that have revolutionized clinical practice.In this context, this research embarked on a comprehensive analysis of the scientific literature to explore the applications and impacts of these technologies on current medical care.Chen, China, 2020 Randomized controlled trials and cohort studies to evaluate the efficacy and safety of telemedicine in the treatment of chronic wounds.
Efficacy results in randomized controlled trials showed no significant difference in wound healing, nor in wound healing at around 1 year.A decreased risk of amputation was revealed in patients who received telemedicine (p = 0.001).The result of the cohort studies showed that telemedicine was more effective than standard care (p < 0.001), while the efficacy of wound healing outcomes around 1 year and 3 months was not significantly different between telemedicine and standard care.Compared to usual care, telemedicine and mobile health had a significantly greater impact on systolic blood pressure control (p<0.001).A subgroup analysis showed that the intervention mode of phone plus SMS text messaging (p < 0.001) or phone only (p<0.001); had a greater impact on systolic blood pressure control than usual care.Among stroke survivors with an intervention interval ≤1 week or baseline systolic blood pressure ≥140 mm Hg, systolic blood pressure control using telemedicine and eHealth was better than usual care 4 48   Odendaal, South Africa, 2020 Studies that used qualitative data collection and analysis methods on eHealth programs.The aim was to synthesize evidence on the perceptions and experiences of health workers on the use of mobile health technologies.
Of note, the mobile devices were loaded with decision support software.Other uses included communicating in person and/or via text messaging, and recording client health information.Improved flexible working.Health workers felt that communicating with clients by cell phone improved care and their relationships with clients, but felt that some clients needed face-to-face contact.Systematic review of randomized clinical trials involving an intervention consisting of an eHealth program using a mobile application in patients after a coronary event.
Improvements and adherence in terms of 6-minute walks and adherence to treatment were achieved in the groups using eHealth (p < 0.001).In addition, the physical and mental dimensions of quality of life were better in the eHealth group (p = 0.01).All-cause and cardiovascular hospital readmissions were statistically higher in the control group than in the eHealth group (p = 0.05).

Eberle, Germany, 2021
Systematic review to determine the impact of diabetes mellitus-specific eHealth applications on glycosylated hemoglobin management.
Overall, there was a clear improvement in glycosylated hemoglobin values.In addition, positive trends toward better self-care and self-efficacy were found as a result of using the eHealth application.

Zhao, China, 2021
Review of randomized controlled trials to evaluate the effectiveness of telehealth interventions to reduce depressive symptoms and anxiety in women with postpartum depression.
Edinburgh Postnatal Depression Scale (p < 0.001) and anxiety (p = 0.005) scores were significantly lower in the telehealth group compared to the control group.Significant differences were found between subgroups in depressive symptoms according to severity of depression, telehealth technology, specific therapy and follow-up time (p < 0.001).
Li, China, 2020 Systematic review with the objective of measuring the effectiveness of eHealth in improving selfmanagement of hypertension in adults.
A greater reduction in both SBP and DBP was observed in the eHealth intervention groups compared with the control groups (p < 0.001; p < 0.001).Sixteen studies reported improved medication adherence and behavioral changes in the intervention groups, while 8 showed no significant changes.

Robson, Australia, 2021
Systematic review of randomized controlled trials that evaluated the effect of one or more types of telehealth interventions on glycosylated hemoglobin levels compared to usual care alone.There was a significant increase in daily step count (p<0.001),moderate and vigorous physical activity (p<0.001), and energy expenditure (p=0.03) and a nonsignificant decrease in sedentary behavior (p=0.08).

Review of randomized controlled trials involving eHealth interventions
for primary prevention in children and adolescents of physical inactivity and sedentary lifestyles.
It showed that studies with high levels of individualization significantly decreased insufficient levels of physical activity (p=0.01), while those with low levels of individualization did not show significant results (p=0.08).
12 Moreno-Ligero, Spain, 2023 Review of articles on the use of eHealth systems on gait and dynamic balance outcomes in subjects with neurological disorders.
A total of 21 mobile applications were identified to train gait and balance, and to improve physical activity behaviors.The findings suggested the use of eHealth systems to improve gait in subjects with neurological disorders, but controversial results were obtained on the recovery of dynamic balance.However, the quality of evidence is insufficient to strongly recommend them, so more research is needed.

13
Jung, Republic of Korea, 2022 Review of randomized controlled trials seeking to improve physical activity through eHealth interventions.
The studies were able to improve physical activity but no significant differences in weight loss were observed when comparing the intervention group with the control groups (p = 0.48).Two studies on the use of apps as eHealth strategies aimed at improving the sexual health of men who have sex with men were analyzed and categorized as decision support systems.In the app libraries, 25 apps were found and analyzed, of which 15 (60%) were available for Android systems, but only 3 (12%) addressed postexposure prophylaxis and were created by researchers from Brazilian universities.The study showed that the eHealth intervention has a significant positive effect on improving institutional delivery (OR = 2.21), utilization of postnatal care (OR = 4.13), and exclusive breastfeeding (OR = 2.25).The intervention has also demonstrated a positive effect on increasing awareness of obstetric danger signs.

24
Mao, China, 2020 Systematic review and meta-analysis to assess the impact of mobile health in countries with different levels of economic development.
There is evidence that eHealth intervention can play an important role in improving clinical outcomes compared to conventional care, as well as having a positive impact in countries with different levels of economic development.Combining eHealth with human intelligence rather than exclusively using eHealth intervention can improve health indicators.

25
Lee, Singapore, 2023 Systematic search to assess eHealth in the management of type 2 diabetes mellitus in the elderly population.

26
Zulu, United Kingdom, 2020 Systematic literature search on the evidence of eHealth and its efficacy in increasing contraceptive use.
A pooled estimate of all studies showed a positive association between telephone messages and contraceptive use, but no clear evidence of benefit (OR 1.12).Most studies evaluated usability with patients (n=29) and health care providers (n=11) compared to healthy users (n=8) and targeted a wide variety of mental health problems (n=24).Half of the studies aimed to assess usability (n=21) and the remainder focused on feasibility (n=10) or acceptability (n=10).The most common reason cited for developing mobile mental health apps was the availability of mobile devices to users, their popularity, and how people in general became accustomed to using them for various purposes.

39
Binyamin, Saudi Arabia, 2021 Meta-analysis study aimed at identifying factors that may affect the acceptance of eHealth.
The study concludes that the key points for acceptance are perceived usefulness, perceived ease of use, attitude towards the behavior, subjective norms and facilitating conditions.The systematic review evaluates mobile telemonitoring strategies in patients with heart failure The risk of bias for mortality and hospitalization was mostly low, whereas for quality of life it was high.A reduction in the risk of hospitalization for heart failure was observed with the use of mobile telemonitoring strategies (RR 0.77).A non-statistically significant reduction in the risk of mortality was observed.The impact on quality of life was variable between studies.

Meyerowitz-Katz, Australia, 2020
The meta-analysis study evaluated dropout rates in chronic disease applications and synthesized possible reasons.
The combined dropout rate was 43% and observational studies had a higher dropout rate (49%).In more controlled settings, which only had a dropout rate of 40 %.In relation to the causes of dropout, social demographic factors were identified.

47
Hyzy, United Kingdom, 2022 Systematic review to evaluate the use of the System Usability Scale (SUS) in digital health applications.
The mean SUS score when all collected apps were included was 76.64 (SD 15.12); however, this distribution showed skewness and was not normally distributed according to the Shapiro-Wilk test (P = 0.002).The mean SUS score for the "physical activity" applications was 83.28 (SD 12.39) and drove skewness.Thus, the mean SUS score for all collected apps, excluding physical activity apps, was 68.05 (SD 14.05).A total of 117 SUS scores were identified for 114 digital health apps.The study highlights that the coverage of maternal health information was positively correlated with the usability score of the apps analyzed.There was no correlation between the usability score and the number of app users, as estimated by the number of app ratings available in the app store.In addition, apps with evidence-based maternal health information had higher engagement, information, and aesthetics scores.However, the presence of evidencebased information did not correlate with a higher number of app users.51 95   Elepaño, Philippines, 2020 The systematic review and metaanalysis aimed to determine the effectiveness of different eHealth interventions in increasing colorectal cancer screening rates.
The study showed low clinical and statistical heterogeneity.Overall, the use of eHealth interventions is associated with higher uptake of colorectal cancer screening compared with usual care.This effect was observed across different types of eHealth interventions, including automated and non-automated telephone education and text message reminders.52 96   Wang, China, 2019 A systematic review was conducted to evaluate the use of eHealth in diabetes mellitus care and reported glycosylated hemoglobin values as a measure of glycemic control.
This study showed a statistically significant decrease in mean glycosylated hemoglobin in the intervention group.The study finds that the combined effect of cell phone messaging increases treatment success compared to standard care.The review included randomized controlled trials on the effect of eHealth on alleviating risk factors for the onset and development of coronary heart disease.
The results showed that mobile health can reduce body mass index (p < 0.05), waist circumference (p < 0.00001), total cholesterol level (p < 0.00001), low-density lipoprotein cholesterol level (p < 0.05), diastolic blood pressure (p < 0.05) and depression (p < 0.05) and increase high-density lipoprotein cholesterol level (p < 0.05) with statistically significant differences.eHealth can alleviate coronary heart disease risk factors and has some effect on the prevention and recovery from coronary heart disease.56 100 Zhong, China,  2023   This systematic review and metaanalysis aimed to evaluate the longterm effectiveness of cardiac telerehabilitation.
The results showed that after cardiac telerehabilitation, there was a significant difference in the improvement in long-term maximal oxygen consumption compared with cardiac rehabilitation in a center (p = 0.01), particularly after 6 months of rehabilitation training (p = 0.02).There was no significant difference in the reduction of cardiovascular risk factor control.There was also no practical demonstration of anxiety or depression scores.
However, cardiac telerehabilitation demonstrated an improvement in patients' long-term quality of life (p = 0.04).In addition, the study reported a high completion rate (80%) of the interventions.The incidence of adverse events was also low during long-term follow-up.
Legend: OR odds ratio, SBP systolic blood pressure, DBP diastolic blood pressure, RR relative risk, SD standard deviation.

DISCUSSION
The countries that contribute most to the subject are China with ten studies, Australia and the United States with five each, and then Germany, Spain and the United Kingdom with three each.The fact that China has a large number of telehealth studies may be due to several reasons: population size, technological advances and health policies, growing investment in research and the high level of international collaboration 101 .
On the other hand, the most studied pathologies were cancer with four studies, cardiovascular disorders with seven studies, metabolic disorders and associated risk factors with six studies, and mental disorders with four studies.
The reason why certain pathologies were more studied may be due to: the high prevalence of these diseases, their severity and high degree of disability to the patient and the need for continuous care.Also, a more profound look to the relation between rehabilitation, psychological factors, workplace professional relationships and telemedicine 102 103 104 105 .
The results of this scientific review provide strong evidence that eHealth interventions have a positive impact on a wide variety of health and wellness areas 45 46 47 .These findings support the growing adoption of eHealth as a valuable tool in health care and health promotion.
In the field of chronic disease management, several studies highlight the usefulness of eHealth.Improvements were observed in the control of systolic blood pressure in stroke survivors and in the management of diabetes mellitus, including a significant reduction in glycosylated hemoglobin levels 46 47 50 .
These results indicate that eHealth can play a crucial role in self-care and chronic disease monitoring, which can improve patients' quality of life and reduce associated risks.
The mobile health practice was shown to be effective in mental health management, with significant reductions in depressive and anxiety symptoms in women with postpartum depression 51 .Linked to this was demonstrated utility in areas such as breastfeeding, physical activity and weight management, where improvements in breastfeeding rate, physical activity and weight loss were observed 61 .
Physical activity promotion has also benefited from eHealth interventions; they have shown that mobile health interventions can increase physical activity in inactive individuals.This finding is particularly relevant at a time when physical inactivity has become a global health problem.App-and device-based interventions have been shown to be effective in motivating people to be active and lead healthier lifestyles 106 107 108 .
Disease-specific disease management has also been an important focus of eHealth, especially those based on interactive short messaging services (SMS), can significantly improve treatment adherence in patients, such as those living with HIV.This is crucial to ensure that these patients receive appropriate care and maintain consistent treatment 65 66 79 .
In addition, usability and acceptability of eHealth technologies are key factors affecting their effectiveness.Binyamin and Inal's studies highlight the importance of eHealth interventions being perceived as useful and easy to use by users, which can influence their adoption and success 82 83 .
It is curious that during the period worked (2018-2023) no meta-analysis studies on clinical trials working Covid-19 disease were found.Everything seems to indicate that it is still early to draw conclusions on the use of technology in the care of this type of patients during the pandemic contingency of 2020 and 2021.
eHealth is proving to be a valuable tool in the transformation of healthcare.From chronic disease management to promoting physical activity and improving treatment adherence, interventions are having a significant impact on the way health care is delivered around the world.However, it is important to recognize that the heterogeneity in outcomes and approaches highlights the need for careful and personalized evaluation of eHealth interventions in different healthcare settings.The future of healthcare will surely continue to see exciting developments in this evolving area.

CONCLUSIONS
Telemedicine studies are notable for addressing a wide variety of pathologies and medical conditions, from cancer to cardiovascular disease, metabolic disorders and mental disorders.This highlights the versatility of telehealth as a valuable approach to improving medical care in diverse areas of health.
There is a strong emphasis on chronic diseases in these studies.Many of the targets focus on conditions that require long-term management and continuous follow-up.This is presented as an effective solution for monitoring and treating these conditions, which can have a positive impact on patients' quality of life.
It should be noted that China is the leading contributor in this area, and that the most studied pathologies include cancer, cardiovascular diseases, metabolic disorders and mental disorders, possibly due to their high prevalence, severity and need for ongoing care.
A common theme in these studies is the focus on improving health outcomes.Whether it is through chronic disease management, promoting healthy lifestyle habits or facilitating access to care, eHealth is presented as an effective tool in the pursuit of positive health outcomes and reducing the burden of disease.
related to telemedicine and eHealth interventions in the control of systolic blood pressure among stroke survivors.
Telehealth interventions were shown to have a stronger influence on HbA1c compared to usual care (p = 0.04).Telehealth interventions, when grouped by type of telemonitoring (mobile health and telephone communication), had a stronger effect on reducing HbA1c levels; however, none of these findings were controlled trials on efficacy of eHealth versus face-to-face interventions for patients living with HIV with smoking.Interventions delivered via eHealth were significantly more effective in increasing smoking cessation than nonintervention control and face-to-face interventions.In the short term, face-to-face interventions were no more effective than no intervention in increasing smoking cessation.In terms of achieving long-term outcomes among people living with HIV, there were no significant differences in smoking cessation rates among those who received eHealth interventions, face-to-face interventions, or no intervention.23 Gayesa, China, 2023 Systematic review to evaluate the effectiveness of mobile health interventions in improving institutional delivery, awareness of obstetric danger signs, and exclusive breastfeeding.
of eHealth interventions in patients diagnosed with tuberculosis were included in the review.
systematic review aimed to analyze fully web-based interventions for people with common mental disorders.All interventions offered algorithm-based screening with measures to assess symptom levels and assign treatment options, including automated web-based psychoeducation, self-care strategies, and signposting to existing services.The study showed that digital interventions improved well-being, mental illness symptoms, and occupational and social functioning.However, some follow-up data failed to show any sustained effect beyond the post-intervention time point.
Flowchart of the state-of-the-art review according to PRISMA methodology.

Table 1 .
Explanatory matrix of the included articles.