A concept of telematics based chronic patient management system is presented, which comprises two main elements: a) the ambulatory systems, an intermittently connectable smart device for patient interfacing, data collection as well as some processing capabilities, and b) the therapy advising tools installed at the departmental, hospital or community sites. The concept proposed rests on a main principle: that chronic patient care based on self-care supported by portable equipments cannot be conceived but integrated with the rest of the available resources that the health care system offers to support current modes of patient treatment, whose efficiency we are trying to enhance.