The Telemedicine at Brazilian Public Policy Management - OfICIAL v3

8/8/2019 The Telemedicine at Brazilian Public Policy Management - OfICIAL v3

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The telemedicine at Brazilian Public Policy ManagementRicardo Matheus

University of São Paulo – USP – BrazilAraújo street, 124. São Paulo – SP – Brazil

+(55)11 [email protected]

Manuella Maia RibeiroUniversity of São Paulo – USP – Brazil

Araújo street, 124. São Paulo – SP – Brazil

+55(11) [email protected]

ABSTRACT

The paper analyzes positive and negative effects of theintroduction of a broad public health policy based ontelemedicine. From the main concepts and definitions of telemedicine should be analyzed the models used worldwide inthe development of this tool of medicine that helps in education,reduction of costs and technological support to other areas of social policies. Best practice in telemedicine will be described inits role in reducing costs of health, minimizing the environmentalimpact of human activities and generate innovation thatencourage citizenship and education.

Categories and Subject Descriptors Management

General Terms Management and Theory.

Keywords Telemedicine; Brazil; e-governance; e-government; PublicHealth.

1. IntroductionAccording to World Health Organization (WHO, 2009), to coverthe provision of telemedicine services to health care is generallyused where the distance is a critical factor. In general, theseservices are provided by health professionals that use of information and communication technologies (ICTs) for theexchange, development and continuing education for providers of health services, and to complete surveys and evaluations.Significant portion of medical specialties has been using ICTs forthe development of medical practice in the distance. Theadoption of telemedicine has occurred in the same proportion of the development of these technologies for communication andinformation, affecting the form of medical approach and creating

an enormous range of possibilities for collaborative services very remote regions (WHITTEN & HOLTZ, 2008th).Among them, the use of telemedicine between the areas oradiology and dermatology (Soirefmann et ali, 2008) where throuting of scanned images of X-rays and computed tomograpof distant places or difficult access shows that the quality of Xray original is as good as the copy sent to the center showing theffectiveness and accuracy of teleradiology (O'SULLIVAN et a1997). Other uses are more familiar: videoconferencing

collaborative work and cases studies, distance education ancontinuous specialization, the update in the area of professiontraining and the second opinion, beyond the consultation onlineHowever, there are authors who suggest other uses fotelemedicine, in addition to the employment of high technologand its high costs. The use of the called ‘ low technology’ and itslow level of complexity and costs should avoid the problem distance in relation to major urban centers and lack of significaamount of human, physical and financial access to the many poto essential health services (SMITH et al, 2005). So, in acoordiwith the brazilian scenario of the internet infra-structure, thpaper believes the public policy of telemedicine in Brazil shouuse the low technology to improve all the country, includinareas that cannot have the access of high technology, such as thhigh connection cable of internet, in contrast of the widespreause of the dial-up connection, an example of low technology.The Telemedicine University Network (RUTE) indicates that tBrazilian shares in telemedicine have been conducted since th1990s, however, still quite limited. A country with continentdimensions, however, it can benefit greatly with the formatioand strengthening of collaborative networks of integrated care a distance. Benefits such as cost reduction in transportation ancommunications and the possibility of introducing a medicspecialist in remote regions of the country (RUTE, 2009).According to resolution 1643/2002 of the Federal Council oMedicine (CFM), in Article 1, the definition of telemedicine the practice of medicine through the use of interactive methods

communication and audiovisual data, with the objective oassistance, education and research in health. However, othdefinitions of telemedicine are also distributed in the AmericTelemedicine Association (ATA), where telemedicine is defineas the use of medical information conveyed from one place another by means of electronic communication, to health aneducation of patients and the medical professional for assistanin improving health.However, one should consider that telemedicine may providebroader purpose than the concepts expressed in the data b

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official organizations and researchers mentioned. Some examplesof cases worldwide in which telemedicine is a simple routine useof the tools of information technology and telecommunications,for a means to achieve goals such as education for citizens, aid ininhospitable places or at critical junctures such as naturaldisasters.These definitions, which cover more purposes for telemedicine,in addition to the basic processes proposed by the organizationsstudied the relationship between patients and professionals in thehealth area, where there is usually a big obstacle as distance,lack of professional and critical moments, such as floods andnatural disasters.

2. Objectives of TelemedicineThe main objectives of telemedicine can be divided into high andlow use of technology in ICT. Examples of high-tech appliancesare more modern and thus more expensive, of which only aportion of the population have access. Broadband is a technologyof the telemedicine service that is not yet widely distributed inBrazil, for example. Alternatively, low ICTs are technologies thatare more widespread, cheaper and with full access population. InBrazil, the Internet dial can be in all the regions.One of the main goals of telemedicine is to study low-costtechnologies that have technical and social in accordance withthe social scenario of most of Brazil's territory. The lowtechnologies such as telephone and internet dial-up connectioncan be widely adopted, favoring the majority of the population,without major investments in technology too expensive that havegreat loss of the depreciation as new products are launched.The universalism of procedures and technological resourcesshould be adopted to improve the collection, processing, analysisand use of information, such as through the introduction of computers in the health sector with efficient and affordable costor using the cellphone which physicians can update patient’s

information and consult information about his historical. For thispolicy is necessary a central data bank and wi-fi internet for thedoctors that are working online, updating and consultinginformation about patients.In summary, the main goals of telemedicine are:

1. Reducing transfers, time and cost of transportingpatients;

2. Improve the management of health resources byevaluating and sorting by experts, reducing thepressure on hospitals;

3. Strengthen cooperation and integration of researcherswith the sharing of clinical records;

4. Allow the process to experts fast in case of disastersand emergencies;

5. Increase the amount of educational programs forphysicians and residents located in areas outside of specialized centers;

6. Develop technologies for transmission of audio, videoand images in health;

7. Build models of information on the Web to improvecommunication and integration of health services.

Some advantages that telemedicine can provide to userprofessionals and, mainly, to the government or entity that yochoose for your use:

1. Reduction of costs of transportation of patients;2. Expansion of access to health, focusing particularly th

use of technologies for large;

3. Human resource development of health in Brazil;4. Easier, faster and more accurate information and

clinical history of the patient;5. Videoconference to obtain second opinions and advic

from experts;6. End of lines through the booking system;7. Rationalization of resources for the health of patient

through triage8. Reduction of space for the storage of data users;9. Standardization of conduct and quality of care;10. Possibility of increased scientific studies through th

selection of cases for the production of research onspecific cases or cohort;However, as with any new process, there are still somdisadvantages involving the use of telemedicine, such as:• Lack of professionals with licenses to perform medica

procedures;• Important changes in the doctor-patient relationship;• Possibility of technological failures;• Implementation can be slow and lack of standardization

especially in large and complex national projects;• Patient loses individual properties and social becoming on

the number and clinical characteristics at the expense of the

individuality;• High cost of telemedicine (equipment, technology, expe

staff in the maintenance of equipment, training of staff);• Possibility of misinterpretation of data and image

transmitted, depending on the quality of the equipment anthe sample sent.

• Need to spend training of Human Resources (HR);• Lack of security and confidentiality of electronic informatio

Ease of access to records and trouble criptogração data and• Possibility of delegation of responsibility for medical or oth

health professionals by person not qualified.

2.1 The use of ICTs and the Rights of theCitizens

The use of ICTs, currently facing struggles for sociaand historical transformations that characterize the movements implementation of the other natural rights. The institutionaconstruction occurs through political and economic disputes anovercome the contradictions between his statement and theffective implementation simple. The materiality of rights therefore an object of a dispute within the different segments



society and state apparatus, not free of setbacks and advances(VAZ, 2005).In the field of telemedicine is no different. You can say that thepossibilities for promotion of citizenship through the Internet canbe understood as those that allow for easier access and theexercise of rights. That is, it is possible to establish a typology of rights that may be impacts of the use of government portals orwebsites (VAZ, 2003), including:• Right to information of particular interest;• Right to public services;• Right to own time;• Right to be heard by the government;• Right to social control of government;• Right to participation in public management.The first three duties are related to the provision of publicservices and access to individual rights. The last three bind to theexercise of collective rights. However, telemedicine can besufficiently advantageous to the country and the interests of the

whole company out of care and service excellence, using thepremise only the rights to their own time and the right to publicservices through the use of ICTs offered by government topromote health care and in telemedicine.Every citizen should be entitled to their own time. While in largecities easy access to health services and better quality, morepeople lacking financial resources and in worse health status,needs to lose a lot of time to move up to the health units of excellence. Technologies included in an essential public servicesuch as health, may help to reduce inequality and provide moretime for the right people. The right to public service is a basicright, provision of the Federal Constitution, so the quality of carein Brazil must cover the entire population of the country. Well ashealth, education is one of the rights of Brazilian citizens, andanother area in which telemedicine can act to provide access topublic education in health.

2.2 The Telemedicine like a tool for theeducationBrazil may have the telemedicine as a support for education andtraining of human health resources in regions that access toinfrastructure, public education is hardly difficulted. The use of the infrastructure of telemedicine ICTs used in diagnoses andtherapeutics while they are not being used can improve theeducation in this regions without human health resources inabundance. The education of health professionals via internetwith classes for graduate and expertise, through distanceeducation, can be a good solution for the lack of certainsprofessionals, the improvement of the professional quality of thephysicians and all the human health resources of the healthsystem, such as nurses and others professionals.The distance education is the teaching-learning process,mediated by technology, where teachers and students can beseparated spatial and/or time (Moran, 1994). One of theproposals addressed to specialization and continuousimprovement of Rh in the tele-health is distance education,through teleconferences and tutorials. The problem-basedlearning (PBL) allows the student to use cases as the stimulus to

develop the skills in problem solving and the acquisition otechnical knowledge (DEMIRIS, 2003).However, a methodology and set minimum standards are needfor the promotion of distance education is carried ousatisfactorily, such as institutional support, planning anstructuring the course, communication between students, suppothe student, evaluate and update the program applied (PHIPPS MERISOTIS, 2000).KELMIS (2007) gives as an example the course of sentinel nofor prevention, early diagnosis and biopsy of breast cancer in tvirtual environment of learning called Modular Object-OrientDynamic Learning Environment (Moodle). The course taught fnine students, all graduate students in medical sciences frodifferent Brazilian states, obtained by continuous access virtuparticipants.The author highlights the importance of planning and schedufor the success of similar experiences. It also highlights the nefor real interest of students, since there is a fundamental factthat these professionals move to the continuing need to updathe labor market.A distance education in health care can reduce costs, improve tquality of medical and hospital care, reduce the need for higratio of medical specialists for people in remote areas, reducinthe number of deaths and avoid unnecessary expenses widiseases whose diagnosis and treatment follow well establishpatterns.

2.3 The Preventive telemedicine and theCitizen EducationFor decades it is known that education can promote cosreduction, improved quality of life and provide better levels human development in the country (SCHALL et al, 1987). Thuse of telemedicine as a form of preventive medicine and citizeeducation, and in the way of the Program Young Doctor (2009in the state of São Paulo and the lower Amazon River regioshould be encouraged.

3. The Telemedicine in BrazilThe growing demand for specialized medical care and training personnel in public health, it is justified and appropriate to thdevelopment of work with telemedicine (OLIVEIRA et al, 200Among the key initiatives and projects implemented itelemedicine in the country, there are Telederma projectNational Project Stocks Permanent Control (ANAPEC).One of the first experiences in teledermatology in Brazil was thTelederma project, involving the department of dermatology the Hospital das Clinicas (UFRGS) and Discipline o

Telemedicine, Faculty of Medicine (USP). The Teledermincluded, in addition to an efficient system for dermatologicinterconsultation internet, educational support by mailing lisclassroom teaching, diagnostic guidelines, drug interaction ansupport for epidemiological surveillance system (MIOT et a2005).The procedures for the consultation was carried out by residenwho, photographed 71 patients of the dermatology clinic and thclinical information entered on the form of the system. Somteachers in a room adjacent to evaluate patients via Internet, an



later live. The percentage of accuracy in diagnosis was 91.5% inremote clinical evaluations and 95.8% in the presence ratings,which showed statistically insignificant difference between themethods of diagnosis (CHAO et al, 2003c).Another concept developed to promote health is the ANAPECwhich included actions to control health strategies disseminatedusing telemedicine, to connect centers of reference and researchassistance to the health units (at different levels), providingcontinuous care and support training of participants involved, aswell as formation of task-forces (including paramedics) foreducation and early detection of diseases (CHAO et al, 2003b).The integration of various centers to allow maintenance of asystem of continuing education, and support high qualitydiagnosis of creating a network of national scope for education,referral of cases (telescreening) and second medical opinion.ANAPEC proposed the use of various technological resources -from the internet by dial up line of videoconferencing systems,depending on the local solution to be viable (MIOT, 2005).The project presents ANAPEC create, in parallel, means fordeploying a network targeted to the detection and diagnosis of leprosy. The training offered to professionals without medicaldegrees would be done with the technology of distance education.These actions could contribute to combating and elimination of leprosy, as an aid to a greater number of persons trained andqualified to undertake the work, the suspected cases would bediscovered and treated more quickly. Therefore, the Departmentof Dermatology and the Discipline of Telemedicine, Faculty of Medicine (USP) developed the project Telemedhansen (MIOT etal, 2005).

3.1 Telemedicine: A solution to the interiorand periphery of cities in Brazil?Authors such as Smith et al (2005) suggest that telemedicine maybe one solution for producing high-quality medicine in placeswhere the distance from large urban centers is a barrier and alsowhere there is lack of human resources, financial and physicalresources to construction of clinical expertise.Recently a group of Brazilians has produced articles showinghow ICTs have been developed and reducing the production costsof equipment and software, especially at low costs to monitor theheart rate - the electrocardiograph (ECG). The softwaredeveloped can be used in low-cost computers to measure heartrate in cases of cardiac dysfunction, and especially patients whohave suffered recent myocardial infarctions (PIMENTA CURY etal, 2005).Estimates suggest the use of telemedicine generates cost savingsin an amount significantly higher than the costs of implementing

the technology. In a scenario of scarcity of resources is necessaryto create models which have wider coverage and lower cost.Thus, telemedicine could be one of the best solutions for accessto health services and preventive diagnosis, care professionalswith better technical quality and reduce transport costs and timeof the citizen (MESSINA et al, 2003).The project Xingú an Indian tribe located in the state of MatoGrosso, for example, we create and implement a care model forhealth monitoring and assistance of health professionals whoprovide assistance to the Xingu Indigenous Park. A major goal

was reducing the time of diagnosis, especially of womenAccording to Lopes et al (2005), it is essential to develop system on internet radio at low cost to facilitate the activities.

3.2 The telemedicine, The Programa Health of family and the use of mobile technologiesICTs have had significant development, with a range oapplications and software created and used extensively fovarious purposes. The area of mobile technologies is also beindeveloped and may be involved in telemedicine projects in tharea of social assistance for the quality of care, provision services and productivity of teams is enhanced and improved.The Brazilian health project called the Family Health Progra(FHP) attempts to implement a strategy of refocusing the healcare model for the design of preventive health, operationalizethrough the establishment of multidisciplinary teams in primahealth care units. The teams are responsible for the monitoring a set number of families, located in an area. The teams operate shares of health promotion, prevention, recovery, rehabilitatioof diseases and disorders more frequent maintenance and healof the community. (BRAZIL, 2009)An interesting strategy would be to research the use otechnology, application and work in the FHP service to thcitizen and the evaluation of its impact on primary health carThe introduction of techniques and equipment used itelemedicine can become a mechanism for ongoing care prevention, diagnosis and treatment of the poor.The use of Internet technology called "3G" (third generation internet) could be used by cellular models of "smart(smartphones), for collection of movies, photos, conditions housing, sanitation, etc..In the state of Ceará, Northeast Brazil, there is an interestinproject developed a network consists of three Faculties oMedicine of the State. The network came by the techniccooperation between the State Health Secretariat of Ceará anthe School of Public Health, the state responsible for thadministration of the PSF. Currently the project aims to traiteachers and students of design and education professionals the medical and public health involved. There is also greainterest in studying methods to prevent and improve thdiagnosis of some diseases such as malignant neoplastidiseases, cardiovascular diseases and infectious diseases, thultrasonographic assessment of high risk pregnant women anmental health, and skin diseases (OLIVEIRA, 2004).

3.3 Telemedicine and costs in Public HealthCosts in health are experiencing an upward trend, due tdemocratization of access to the Brazilian health system and althe expensive prices and values of goods and services in thworld market due to the own demand. This has been thdifficulty with which to finance these costs is leading servicproviders, donors, health authorities and the users arincreasingly concerned with the cost of health services and iconsequences on the quality of those services.Telemedicine can be an interesting way to avoid waste oresources and to enhance the efficiency of public social policieExamples of increased efficiency and decreased costs arobserved in some countries that have implemented



telemedicine. Recent studies show that in England, 17% of patients with burns were conducted via telemedicine monitoringthrough videoconferencing.1000 The number of contacts between large medical centers andthe country reduced the emission of carbon dioxide by 39 tonsper year, from trips that patients should be done to achieve thesame query performed without the use of telemedicine (Smith etal , 2007). In the UK believed to have reduced by 20% the totalemission of carbon dioxide annually, from the burning of fossilfuels to displacement of patients and health teams(PATTERSON, 2005). Brazil can use the technique to reducecosts and carbon dioxide emissions from travel and travel forpatients and health teams.The sustainability of telemedicine in a hospital, observed inrecent studies that suggest that telemedicine, as well as reducecosts, it also creates opportunity for expanding the productivity of services to the population (MEDEIROS & WAINER, 2004).For example, the MedMail Project has the objective to providean operating system of medical collaboration to exchangemessages and medical files, using free software. The mainreasons for introducing this software is the development of client-server in health care only to collect information for thearea, facilitating the interaction of professionals and improvingthe quality of the organization and its functioning (LOPES et al,2005) . The design allows storage of large volumes of information in order to establish a collaborative network of second opinion. The system allows use of good quality images,even when there is no use of broadband Internet, or at very lowcost and very universal access in Brazil.Some researchers support the idea of using the second opinion asone of the approaches to telemedicine, as shown improvement inthe quality of diagnosis and reducing the time used for thecertification of this diagnosis (MEDEIROS & Wainer, 2008).However, technology is very expensive, therefore the need of video equipment very expensive and become obsolete quickly,because the speed of innovations in the area.

4. Final ConsiderationsThe growth of technological innovations in computing, high-resolution digital images, robotics and Internet had a majorimpact on how the information is now available in medicine.Telemedicine has become an important factor in the care of thepatient and has been used increasingly to provide care andeducation (DEMIRS, 2003).Telemedicine should be considered a model of health care withthe potential to offer high-quality medicine to the isolatedpopulations without access to health. Moreover, it serves asimportant tool in the teaching of medicine, by offering aneffective alternative and within easy access of medical education(Kim, 2004). Therefore, the practice of telemedicine as a tool of education can facilitate the process of education, both at thegraduate and continuing medical education of healthprofessionals.Although the proportion of doctors trained in Brazil is close of the recommendations highlighted by the World HealthOrganization (WHO, 2009), the geographical distribution haslack in some areas and substantial concentration in large urban

centers. The government has emphasized efforts to programs fprimary care, given the social reality, as the case of the FamiHealth Program (PSF) and the internalization of the WorProgram in Health (PITS), besides increasing the quality aninfrastructure of National Research Network (RNP) and thTelemecidicine University Network (RUTE).However you should understand that telemedicine should bencouraged by the government. According to Lopes et al (2005the correct diagnosis is made in 55% of cases, only the patienclinical history. The chances of success increased by 20% withe implementation of clinical and more 20%, from additiontests.So if the technology can expand the scope for adjustment of thtraditional model of medical diagnosis of a low cost witincreased productivity and coverage, you should walk a path investment and encourage researchers from all areas to improthe public health service through the targeting of efforts omultidisciplinary characteristic of telemedicine.

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[38] WHITTEN, Pamela & HOLTZ, Bree. A Series of Papers forThose Yearning to Propel Telehealth to New Heights.Telemedicine and e-Health. Vol. 14, No. 9: 952-956. Nov2008b.

[39] WOOTON, R. Recent advances: Telemedicine. BMJ. 2001

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