In discussions around digital health, in-person care and remote care are still often described as alternative approaches. In reality, the real challenge is not choosing one over the other, but integrating them into a single, coherent and continuous clinical pathway, especially in the management of chronic conditions.

An integrated care model does not mean “using telemedicine from time to time.” It means designing a unified clinical pathway in which each modality has a precise role: some phases necessarily require the patient’s physical presence—such as complex initial assessments, key decision points or specific diagnostic tests—while others can be managed remotely without any loss of clinical quality, including monitoring, follow-up, therapeutic adjustments and structured counselling.

The quality of this model depends on continuity. Remote activities must rely on the same clinical references, documentation standards and health records that guide in-person visits. Otherwise, the risk is the creation of parallel pathways that fail to communicate with each other.

The most delicate aspect is the transition between different care settings.

When data collected remotely remain separate from the electronic health record, the integrated model loses effectiveness and generates fragmentation: more tools, more channels, less clarity. When information flows are fully integrated, remote care strengthens patient management by enabling longitudinal analysis, early identification of critical issues, improved therapeutic adherence and a reduction in unnecessary in-person visits—without disrupting the continuity of care.

To function effectively, an integrated care model requires several essential operational conditions. First, integration with the electronic health record and related clinical processes. Second, the traceability of remote clinical activities, ensuring that every intervention is documented and verifiable. Finally, the clear definition of roles, responsibilities and decision thresholds: who monitors which data, when to intervene and according to which criteria.

When these conditions are met, in-person and remote care cease to be opposing modalities and become two expressions of the same clinical work.