Providing Telehealth Services to a Public Primary Care Network: The Experience of RedeNUTES in Pernambuco, Brazil Paula Rejane Beserra Diniz, PhD, 1,2 Fernando José Ribeiro Sales, PhD, 1,3 and Magdala de Araújo Novaes, PhD 1,2 1 Telehealth Center, Clinics Hospital, Federal University of Pernambuco, Recife, Brazil. 2 Internal Medicine Department, Medical School, Federal University of Pernambuco, Recife, Brazil. 3 Biomedical Engineering Department, Centro de Tecnologia e Geociências (CTG), Federal University of Pernambuco, Recife, Brazil. Abstract Background: Information technologies have been applied in primary care domains to improve the delivery of health services. This article reports the telehealth network experience in Pernambuco, Brazil. Materials and Methods: Five different data sets were used, one by each service and the structural aspects of the network, collected from 2008 until August 2015. The data include solicited themes for educational activities, users evaluation of services, numbers of sites, municipalities participating, participants in tele-education activities, teleconsultations, telediagnosis, and remote screenings. The analysis was done in absolute and percentage values using Microsoft Excel (version 2007). Results: The indicators show high utilization of tele-education resources, followed by the teleconsultation service. The synchronous modality was the most used and the general clinical question was the most frequent type of question. Nurses are the professional category that most used the teleconsultation services (36%). Telediagnosis of electrocardiography has growth utilization, overcoming teleconsulting more recently. The satisfaction rate was 89%, and 68.5% of professionals changed their planning to patients referrals to specialists. Conclusions: Telehealth has been considered effective since it avoids inappropriate referrals of the patient and provides continuous actualization to health professionals. Our results provide evidence of the feasibility and importance of using telehealth as a tool to ensure the universality, equality, and completeness in the health system. Key words: e-health, m-health, telehealth, telemedicine Introduction Brazilian public health system, the Unified Health System (SUS) created in 1988 by the Federal Constitution, has been based on some noble, but complex, premises. The first one is that health is a right of the citizen and a duty of the State and SUS must achieve the following principles: universality, integrality, and gratuity. Three levels of power share the responsibility of health services: Federal, State, and Municipal Governments. 1 The provision of healthcare services for a population of 100 million inhabitants in a continental country such as Brazil presenting several different regional realities is a real challenge that is still not completely solved. 1 The SUS has three different attention levels, where primary care is usually the entrance for the majority of the population. 1 Primary care is the first level of the healthcare network and provides health services to a large portion of the population. The operationalization of this model needs integration with other levels of care; information sharing continued actualization of professionals and facilitated communication with specialists. 2,3 In this way, information technologies have been applied in primary care domains to improve the delivery of health services. Together, these mechanisms are known as telehealth. 4 6 In Brazil, strategies for the use of telehealth are centralized in Brazil Telehealth Network Program, which was created and headed by the Brazilian Ministry of Health. 7 It proposes the integration of primary care professionals with medical schools to improve the quality of services and reduce costs, through professional qualification, and the amount of unnecessary travel by patients to capital hospitals. 6 Pernambuco was one of first nine Brazilian states to implement telehealth to connect university specialists to basic assistance. The state has about 98,311 km 2, 9 million inhabitants distributed in 185 municipalities, a high population concentration along the coast, vast rural areas with low human development index, and few health professionals in these regions. 8 In this scenario, telehealth is strategic to improve the quality of care in these rural areas. The Telehealth Center (NUTES) was created in 2003 in Clinics Hospital of Federal University of Pernambuco; on this occasion, a regional 694 TELEMEDICINE and e-health AUGUST 2016 DOI: 10.1089/tmj.2015.0209
TELEHEALTH IN PRIMARY CARE: REDENUTES EXPERIENCE telehealth network was established and named RedeNUTES. 9 In 2007, NUTES received financial support from the Ministry of Health to expand the network and to deliver services essentially to primary care facilities. 10 Thetelecareservicesoffered include teleconsultation, telediagnosis, tele-education, and remote screening, provided through a Web page, Web conferencing application, a virtual learning environment (VLE), asynchronous telehealth platform, and mobile applications. 11 Tele-education is characterized as a set of educational activities, seminars, and courses, preferably involving topics based on local demand or suggested by healthcare managers or public health professionals. 10,12 The synchronous sections occur weekly, and the recorded materials are made available on VLE for further consulting. Teleconsultation is a registered consulting service among healthcare workers, professionals, and managers using bidirectional telecommunication tools to clarify doubts related to clinical procedures, healthcare practices, or working flows. 10 Already, the reporting process of medical examinations remotely by specialists is defined as telediagnosis. 10 In the RedeNUTES case, just the tele-electrocardiography (tele-ecg) approach was implemented, despite that our telehealth platform has been enabled to receive other modalities of telediagnosis using medical images such as teledermatology. In both services, teleconsultants have a term of up to 72 h to give the first response to the requester. Remote screening or telescreening is a new service in the network, not yet specified by the Health Ministry. It corresponds to disease screenings in the patient s home, schools, or healthcare institutions through mobile applications. The interview is structured to guide the examination. After, screening information can be discussed with a teleconsultant to define the clinical conduct. Therefore, the aim of this article is to report on 8 years of RedeNUTES experience and discuss the factors associated with the telehealth service utilization in the reality of Pernambuco, in the context of primary care level of SUS. Materials and Methods This article is a descriptive study of the telehealth services developed in Pernambuco by RedeNUTES, with the focus on teleconsultation, telediagnosis, remote screening, and teleeducation. Five different data sets were used, one by each service and the structural aspects of the network, collected from 2008 until August 2015 by our health information systems. In the first step, the complete database was analyzed, and we selected the variables of interest. All data used were made anonymous before being exported to our database. We thus had no access to any patient or professional identification. The data reflect the utilization aspects and include solicited themes for educational activities, user s evaluation of services, numbers of sites, municipalities participating, participants in tele-education activities, teleconsultations, telediagnosis, and remote screenings. Then, we conducted the descriptive statistical analysis using absolute and percentage values. We utilized Microsoft Excel (version 2007) for this step. Results and Discussion RedeNUTES is now present in 106 municipalities with 411 telehealth sites, benefiting more than 3,000 professionals, and 862,500 people attended health facilities. Figure 1 shows the evolution of the number of municipalities using our services and the number of active telehealth sites in the period from 2008 to 2015. Each site is a healthcare facility with a computer on the Internet. In this figure, only active sites have been considered, those who consumed some of our services that year. In the period of 2011 2013, a fluctuation in the number of active sites was observed and, consequently, in the number of cities attended. Several reasons can explain this variation, but the most frequent reason was the connectivity issues in the primary care facilities; some municipalities have not renewed their Internet contracts with the service providers or had infrastructural problems in healthcare facilities such as nonexistent or inefficient repair contracts for the computers. For example, in a recent inquiry, we found that only 30% of the municipalities have a good quality Internet link. In Figure 2, it is possible to analyze the evolution of our delivered services. In 2008, only tele-education initiatives were provided to members of RedeNUTES, and the teleconsulting service was started only in 2009. In 2011, tele-ecg was added to our services, and in 2013, remote screening focused on mental health was also provided. From 2008 to 2010, there was an increase in the usage of related services. However, this rising trend has changed in the next 2 years, 2011 and 2012, where teleconsultation, telediagnosis, and tele-education indicators were reduced. From 2013 to the present time, tele-education and telediagnosis have returned to present a rising trend, which started in 2014 for the teleconsultation services. Remote screening actions for mental health were initialized in 2013 by a pilot research study that achieved several conclusions. However, during the current year, this service has been reformulated to match some of the patients needs. One of the reasons associated with observed reduction was the change in the National Brazil Telehealth Program, which has been financing these activities. Until 2010, Telehealth Center was in charge of providing the remote services and local ª MARY ANN LIEBERT, INC. VOL. 22 NO. 8 AUGUST 2016 TELEMEDICINE and e-health 695
DINIZ ET AL. Fig. 1. Temporal series of active telehealth sites and municipalities participating in the RedeNUTES Network. computational infrastructure to the healthcare facilities, thus ensuring the quality that allowed the use of services on our sites. The indicators show high utilization of tele-education resources, followed by the teleconsultation service (Table 1). The mean number of participants per tele-education session was 36 and approximately four people per site. The mean number of teleconsultations per municipality per month was about 1, which is similar to other telehealth services in Brazil. 5 The synchronous modality was the most used and the general clinical question was the most frequent type of question. Nurses are the professional category that most used the teleconsultation services (36%). Physicians, in turn, correspond to only 8% of teleconsultation users. These data are proportional to the number of professionals available for each category in the state, 28% and 5%, respectively. 8 However, a greater awareness of telehealth use is necessary, especially among physicians. Telediagnosis and telescreening were recently offered, which can explain the small relative utilization. However, the lack of required infrastructure, not provided by the municipalities, also contributes to low numbers. However, in the temporal series analysis, it is possible to see an interesting growth utilization of tele-ecg, overcoming the teleconsulting more recently. The electrocardiogram is a noninvasive technique that allows the assessment of the electrical activity of the heart, presenting significant clinical relevance, low level of operator dependence, and relatively low cost. It is an important method for cardiovascular system investigation, especially for chronic Fig. 2. Distribution of telehealth services provided from 2008 to 2015. 696 TELEMEDICINE and e-health AUGUST 2016 ª MARY ANN LIEBERT, INC.
TELEHEALTH IN PRIMARY CARE: REDENUTES EXPERIENCE Table 1. Main Indicators of Our Telehealth Service Results from 2008 to 2015 SERVICE INDICATOR BRIEF DESCRIPTION TOTAL Tele-education Seminars Number of Web seminars provided. 882 Participants Quantification of the audience of Web seminars. 8,570 Teleconsultation 7,884 Asynchronous Synchronous Clinical case discussion General clinical question Workflow question Questions sent to our team and answered by the consultant under request. Requesting professional and teleconsultant are together in same communication channel. Question related to a specific patient, usually with an electronic health record, to describe his current health profile and his previous medical history. Consists of a general question without association with a real patient. Usually related to details or steps from daily working process. Telediagnosis a 2,555 ECG reports Primary care health professionals with an EGG device perform the examination that is reported remotely by a specialist. Remote screenings b 128 Mental health 128 a Used only by three municipalities. b Available only for one municipality. ECG, electrocardiography. diseases, which explains the elevated pent-up demand of tele- ECG service in primary care. 13 In the national scene, telediagnosis starts as the most used service and can still improve its indicators, 14 probably this can be attributed to the repressed demand for ECG in primary care. In our teleconsultation platform HealthNet, 15 some information about satisfaction and clinical conduct must be provided before the request be completed. During the analyzed period, 2,040 users responded to a questionnaire that showed 89% satisfaction level. About 1,334 professionals answered the question about their conduct after the teleconsultation, and 68.5% said that they changed their planning to patients referrals to specialists. This result confirms that telehealth is important to avoid unnecessary costs for the health system and improve the primary care resoluteness. Conclusion This study showed the use of telehealth services offered by RedeNUTES in the state of Pernambuco. Telehealth has been 2,393 5,491 1,587 3,312 592 2,555 considered effective since it avoids inappropriate referrals of the patient and provides continuous actualization to health professionals. Despite the potential to increase the quality of health services in primary care and the current disponibility of services to more than 100 cities, our utilization indexes are still below our expectations and our services remain underutilized. Several managers have reported infrastructural and connectivity issues. However, the resistance of healthcare professionals still plays a significant role in this case. For some professionals, to use the teleconsultation services represents an increase on their consultation time and workload, which discourages them from adopting these services into their daily practice. As long as the choice of usage of telehealth services in primary care remains only on thehealthcareprofessional,thisapproach will be vulnerable and, possibly, underutilized in the Brazilian SUS. More recently, the Federal Government invested in a free telephone line for teleconsultations and has incentivized the municipalities to use it as a tool to qualify the referral of patients on the healthcare system. However, this process remains as an option and depends on the local political arrangements. Public policies should be implemented by the government to assure the utilization of these tools by the professionals. Otherwise, the high investments that have been made over the years will be prone to underutilization and slowly crumble, wasting the hopes of primary care users of Brazilian SUS. Our results provide evidence of the feasibility and importance of using telehealth as a tool to ensure the universality, equality, and completeness in the health system. Acknowledgments The RedeNUTES Network is mainly funded by the Ministry of Health and the Ministry of Science and Technology. Disclosure Statement No competing financial interests exist. ª MARY ANN LIEBERT, INC. VOL. 22 NO. 8 AUGUST 2016 TELEMEDICINE and e-health 697
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