A telehealth integrated asthma/COPD service for primary care

Good practice:

Better diagnosis and treatment by improving communication between primary and secondary care

NORTHERN NETHERLANDS  / Asthma/COPD Telehealth service:  76/11473 8/350

Asthma and Chronic Obstructive Pulmonary Disease (COPD) are examples of prevalent chronic diseases in primary care. Worldwide, approximately 300 million people have asthma and 65 million people suffer from moderate to severe COPD. In the Netherlands, 60% to 80% of all asthma and COPD patients are treated by their GP. Patients are only referred to the pulmonologists in case of uncontrolled asthma or severe COPD.

Customer's need

Diagnosing and distinguishing asthma from COPD and other pulmonary problems is difficult. Asthma and COPD overlap in symptoms, while the treatments of asthma and COPD are different. To make things more challenging, some patients have an asthma-COPD overlap syndrome (ACOS). Which can be described as a (partly) reversible, but progressive deterioration in lung function. Often combined with a history of smoking, and previous diagnosis of asthma and or allergies.

The solution

In general, ACOS patients are younger than COPD patients. They have more exacerbations and hospitalisations compared to COPD or asthma patients. A careful study of a patient’s history is the cornerstone in the diagnosticprocess. Spirometry is an important instrument to confirm or reject the working diagnosis. Performing spirometry in primary care and interpreting the results is complicated.

We developed the Asthma/COPD (AC) telehealth management support service for asthma and COPD patients in primary care. It helps GPs examine patients and provides detailed advice from pulmonologists to the GPs. AC is accurate, comprehensive and short enough to be used by the GP in daily clinical practice. The service is easily accessible for GPs and patients in rural areas. Each patient with suspected asthma, COPD, ACOS or pulmonary symptoms of unknown origin is eligible for inclusion.

Keys to success

  • Structuring the collection of the data through a web-based Electronic Diagnostic Support (EDS) system helps communication between primary and secondary healthcare workers.
  • Cooperation from the very start of the project results in clear collaboration between GPs and pulmonologists. Preventing suspicion and opposition.
  • The GP has the lead role and is the initial point of contact. The pulmonologist is more of an advisor.

Good practice: Better diagnosis and treatment by improving communication between primary and secondary care.

Good practice description

For chronic patients, integrated care should result in improvements in the quality of the care process, especially with regard to effectiveness, patient-centred attitude, continuity, accessibility, integration and efficiency.

Automation is necessary to prevent miscommunication between healthcare providers, and to realise a structured data assessment making each decision and the results of that decision transparent for follow up.

"Early involvement of both primary and secondary healthcare professionals in the process is key for obtaining successful care coordination."

Good practice example

The main challenge of the asthma/COPD telehealth service is to overcome preconceived opinions of general practitioners and pulmonologists. In fact, they have to work together for optimal patient management. General practitioners fear losing patients when they refer them to the hospital. Pulmonologists, on the other hand, hesitate to refer patients back to primary care physicians, claiming they provide insufficient care. An open discussion with both parties at the very start of the project resulted in clear agreements about the collaboration between general practitioners and pulmonologists. This prevented suspicion and opposition. This solid base is necessary for developing a successful integrated care protocol.

The program

Four starting principles are defined:

  • Integrated care should optimize the diagnosis, treatment and management of patients with asthma and/or COPD
  • The general practitioner(GP) is the leading organiser.
  • Integrated care should be easy accessible for both patients and healthcare providers in both primary and secondary care.
  • The allocation of tasks and cooperation between primary and secondary care has to be clearly defined.

Patients enter the integrated care service after being invited by their GP. Usually because of previous use of inhaled medication, or because the patient presents pulmonary symptoms. 

To optimize the diagnostic process, the quality of the lung function tests has to be high. The retrieval of other data, like medical history and health status measurements, should be concise.

Performed in a uniform and transparent way. For quality reasons, these tasks are given to specially trained lung function assistants from a primary care diagnostic service. The medical history data is then fed into the Electronic Data System (EDS), together with the result of the lung function test. Flowcharts based on international guidelines are created for the EDS system. Lung function data is combined with the CCQ and ACQ scores to generate automated therapeutic advice.

This computerised advice, in combination with the outcomes of the patient history, forms the basis of the final diagnosis and treatment. Advice is then given by the pulmonologist to the GP. In case a change in therapy is advised, patients are automatically scheduled for a follow-up visit to the primary care asthma/COPD diagnostic service after three months. In all other cases, patients have an annual follow-up. Guaranteeing the continuity of care.

Contact information

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SProf.dr. Thys van der molen


  • Metting EI, Riemersma RA, Kocks JH, Piersma-Wichers MG, Sanderman R, van der Molen T. Feasibility and effectiveness of an Asthma/COPD service for primary care: a cross-sectional baseline description and longitudinal results. NPJ Prim Care Respir Med. 2015 Jan 8;25:14101.

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