The telemedicine at Brazilian Public Policy Management
Ricardo Matheus Manuella Maia Ribeiro
University of São Paulo – USP – Brazil
Araújo street, 124. São Paulo – SP – Brazil
+(55)11 7227-7521
ricardomatheus@gmail.com
ABSTRACT
The paper analyzes positive and negative effects of the
introduction of a broad public health policy based on
telemedicine. From the main concepts and definitions of
telemedicine should be analyzed the models used worldwide in
the 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 in
its role in reducing costs of health, minimizing the environmental
impact of human activities and generate innovation that
encourage citizenship and education.
Categories and Subject Descriptors
Management
General Terms
Management and Theory.
Keywords
Telemedicine; Brazil; e-governance; e-government; Public
Health.
1. Introduction
According to World Health Organization (WHO, 2009), to cover
the provision of telemedicine services to health care is generally
used where the distance is a critical factor. In general, these
services are provided by health professionals that use of
information and communication technologies (ICTs) for the
exchange, development and continuing education for providers of
health services, and to complete surveys and evaluations.
Significant portion of medical specialties has been using ICTs for
the development of medical practice in the distance. The
adoption of telemedicine has occurred in the same proportion of
the development of these technologies for communication and
information, affecting the form of medical approach and creating
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University of São Paulo – USP – Brazil
Araújo street, 124. São Paulo – SP – Brazil
+55(11) 7633-1678
maiamanuella@gmail.com
an enormous range of possibilities for collaborative services in
very remote regions (WHITTEN & HOLTZ, 2008th).
Among them, the use of telemedicine between the areas of
radiology and dermatology (Soirefmann et ali, 2008) where the
routing of scanned images of X-rays and computed tomography
of distant places or difficult access shows that the quality of X-
ray original is as good as the copy sent to the center showing the
effectiveness and accuracy of teleradiology (O'SULLIVAN et al,
1997). Other uses are more familiar: videoconferencing,
collaborative work and cases studies, distance education and
continuous specialization, the update in the area of professional
training and the second opinion, beyond the consultation online.
However, there are authors who suggest other uses for
telemedicine, in addition to the employment of high technology
and its high costs. The use of the called ‘low technology’ and its
low level of complexity and costs should avoid the problem of
distance in relation to major urban centers and lack of significant
amount of human, physical and financial access to the many poor
to essential health services (SMITH et al, 2005). So, in acoording
with the brazilian scenario of the internet infra-structure, this
paper believes the public policy of telemedicine in Brazil should
use the low technology to improve all the country, including
areas that cannot have the access of high technology, such as the
high connection cable of internet, in contrast of the widespread
use of the dial-up connection, an example of low technology.
The Telemedicine University Network (RUTE) indicates that the
Brazilian shares in telemedicine have been conducted since the
1990s, however, still quite limited. A country with continental
dimensions, however, it can benefit greatly with the formation
and strengthening of collaborative networks of integrated care at
a distance. Benefits such as cost reduction in transportation and
communications and the possibility of introducing a medical
specialist in remote regions of the country (RUTE, 2009).
According to resolution 1643/2002 of the Federal Council of
Medicine (CFM), in Article 1, the definition of telemedicine is
the practice of medicine through the use of interactive methods of
communication and audiovisual data, with the objective of
assistance, education and research in health. However, other
definitions of telemedicine are also distributed in the American
Telemedicine Association (ATA), where telemedicine is defined
as the use of medical information conveyed from one place to
another by means of electronic communication, to health and
education of patients and the medical professional for assistance
in improving health.
However, one should consider that telemedicine may provide a
broader purpose than the concepts expressed in the data by
official organizations and researchers mentioned. Some examples
of cases worldwide in which telemedicine is a simple routine use
of the tools of information technology and telecommunications,
for a means to achieve goals such as education for citizens, aid in
inhospitable places or at critical junctures such as natural
disasters.
These definitions, which cover more purposes for telemedicine,
in addition to the basic processes proposed by the organizations
studied the relationship between patients and professionals in the
health area, where there is usually a big obstacle as distance,
lack of professional and critical moments, such as floods and
natural disasters.
2. Objectives of Telemedicine
The main objectives of telemedicine can be divided into high and
low use of technology in ICT. Examples of high-tech appliances
are more modern and thus more expensive, of which only a
portion of the population have access. Broadband is a technology
of the telemedicine service that is not yet widely distributed in
Brazil, for example. Alternatively, low ICTs are technologies that
are more widespread, cheaper and with full access population. In
Brazil, the Internet dial can be in all the regions.
One of the main goals of telemedicine is to study low-cost
technologies that have technical and social in accordance with
the social scenario of most of Brazil's territory. The low
technologies such as telephone and internet dial-up connection
can be widely adopted, favoring the majority of the population,
without major investments in technology too expensive that have
great loss of the depreciation as new products are launched.
The universalism of procedures and technological resources
should be adopted to improve the collection, processing, analysis
and use of information, such as through the introduction of
computers in the health sector with efficient and affordable cost
or using the cellphone which physicians can update patient’s
information and consult information about his historical. For this
policy is necessary a central data bank and wi-fi internet for the
doctors that are working online, updating and consulting
information about patients.
In summary, the main goals of telemedicine are:
1. Reducing transfers, time and cost of transporting
patients;
2. Improve the management of health resources by
evaluating and sorting by experts, reducing the
pressure on hospitals;
3. Strengthen cooperation and integration of researchers
with the sharing of clinical records;
4. Allow the process to experts fast in case of disasters
and emergencies;
5. Increase the amount of educational programs for
physicians and residents located in areas outside of
specialized centers;
6. Develop technologies for transmission of audio, video
and images in health;
7. Build models of information on the Web to improve
communication and integration of health services.
Some advantages that telemedicine can provide to users,
professionals and, mainly, to the government or entity that you
choose for your use:
1. Reduction of costs of transportation of patients;
2. Expansion of access to health, focusing particularly the
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 advice
from experts;
6. End of lines through the booking system;
7. Rationalization of resources for the health of patients
through triage
8. Reduction of space for the storage of data users;
9. Standardization of conduct and quality of care;
10. Possibility of increased scientific studies through the
selection of cases for the production of research on
specific cases or cohort;
However, as with any new process, there are still some
disadvantages involving the use of telemedicine, such as:
• Lack of professionals with licenses to perform medical
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 only
the number and clinical characteristics at the expense of their
individuality;
• High cost of telemedicine (equipment, technology, expert
staff in the maintenance of equipment, training of staff);
• Possibility of misinterpretation of data and images
transmitted, depending on the quality of the equipment and
the sample sent.
• Need to spend training of Human Resources (HR);
• Lack of security and confidentiality of electronic information.
Ease of access to records and trouble criptogração data and
• Possibility of delegation of responsibility for medical or other
health professionals by person not qualified.
2.1 The use of ICTs and the Rights of the
Citizens
The use of ICTs, currently facing struggles for social
and historical transformations that characterize the movements of
implementation of the other natural rights. The institutional
construction occurs through political and economic disputes and
overcome the contradictions between his statement and the
effective implementation simple. The materiality of rights is
therefore an object of a dispute within the different segments of
society and state apparatus, not free of setbacks and advances
(VAZ, 2005).
In the field of telemedicine is no different. You can say that the
possibilities for promotion of citizenship through the Internet can
be understood as those that allow for easier access and the
exercise of rights. That is, it is possible to establish a typology of
rights that may be impacts of the use of government portals or
websites (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 public
services and access to individual rights. The last three bind to the
exercise of collective rights. However, telemedicine can be
sufficiently advantageous to the country and the interests of the
whole company out of care and service excellence, using the
premise only the rights to their own time and the right to public
services through the use of ICTs offered by government to
promote health care and in telemedicine.
Every citizen should be entitled to their own time. While in large
cities easy access to health services and better quality, more
people 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 service
such as health, may help to reduce inequality and provide more
time for the right people. The right to public service is a basic
right, provision of the Federal Constitution, so the quality of care
in Brazil must cover the entire population of the country. Well as
health, education is one of the rights of Brazilian citizens, and
another area in which telemedicine can act to provide access to
public education in health.
2.2 The Telemedicine like a tool for the
education
Brazil may have the telemedicine as a support for education and
training of human health resources in regions that access to
infrastructure, public education is hardly difficulted. The use of
the infrastructure of telemedicine ICTs used in diagnoses and
therapeutics while they are not being used can improve the
education in this regions without human health resources in
abundance. The education of health professionals via internet
with classes for graduate and expertise, through distance
education, can be a good solution for the lack of certains
professionals, the improvement of the professional quality of the
physicians and all the human health resources of the health
system, such as nurses and others professionals.
The distance education is the teaching-learning process,
mediated by technology, where teachers and students can be
separated spatial and/or time (Moran, 1994). One of the
proposals addressed to specialization and continuous
improvement of Rh in the tele-health is distance education,
through teleconferences and tutorials. The problem-based
learning (PBL) allows the student to use cases as the stimulus to
develop the skills in problem solving and the acquisition of
technical knowledge (DEMIRIS, 2003).
However, a methodology and set minimum standards are needed
for the promotion of distance education is carried out
satisfactorily, such as institutional support, planning and
structuring the course, communication between students, support
the student, evaluate and update the program applied (PHIPPS &
MERISOTIS, 2000).
KELMIS (2007) gives as an example the course of sentinel node
for prevention, early diagnosis and biopsy of breast cancer in the
virtual environment of learning called Modular Object-Oriented
Dynamic Learning Environment (Moodle). The course taught for
nine students, all graduate students in medical sciences from
different Brazilian states, obtained by continuous access virtual
participants.
The author highlights the importance of planning and schedule
for the success of similar experiences. It also highlights the need
for real interest of students, since there is a fundamental factor
that these professionals move to the continuing need to update
the labor market.
A distance education in health care can reduce costs, improve the
quality of medical and hospital care, reduce the need for high
ratio of medical specialists for people in remote areas, reducing
the number of deaths and avoid unnecessary expenses with
diseases whose diagnosis and treatment follow well established
patterns.
2.3 The Preventive telemedicine and the
Citizen Education
For decades it is known that education can promote cost
reduction, improved quality of life and provide better levels of
human development in the country (SCHALL et al, 1987). The
use of telemedicine as a form of preventive medicine and citizen
education, and in the way of the Program Young Doctor (2009),
in the state of São Paulo and the lower Amazon River region
should be encouraged.
3. The Telemedicine in Brazil
The growing demand for specialized medical care and training of
personnel in public health, it is justified and appropriate to the
development of work with telemedicine (OLIVEIRA et al, 2004).
Among the key initiatives and projects implemented in
telemedicine in the country, there are Telederma project,
National Project Stocks Permanent Control (ANAPEC).
One of the first experiences in teledermatology in Brazil was the
Telederma project, involving the department of dermatology at
the Hospital das Clinicas (UFRGS) and Discipline of
Telemedicine, Faculty of Medicine (USP). The Telederma
included, in addition to an efficient system for dermatological
interconsultation internet, educational support by mailing list,
classroom teaching, diagnostic guidelines, drug interaction and
support for epidemiological surveillance system (MIOT et al,
2005).
The procedures for the consultation was carried out by residents
who, photographed 71 patients of the dermatology clinic and the
clinical information entered on the form of the system. Some
teachers in a room adjacent to evaluate patients via Internet, and
later live. The percentage of accuracy in diagnosis was 91.5% in
remote clinical evaluations and 95.8% in the presence ratings,
which showed statistically insignificant difference between the
methods of diagnosis (CHAO et al, 2003c).
Another concept developed to promote health is the ANAPEC
which included actions to control health strategies disseminated
using telemedicine, to connect centers of reference and research
assistance to the health units (at different levels), providing
continuous care and support training of participants involved, as
well as formation of task-forces (including paramedics) for
education and early detection of diseases (CHAO et al, 2003b).
The integration of various centers to allow maintenance of a
system of continuing education, and support high quality
diagnosis 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 for
deploying a network targeted to the detection and diagnosis of
leprosy. The training offered to professionals without medical
degrees 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 and
qualified to undertake the work, the suspected cases would be
discovered and treated more quickly. Therefore, the Department
of Dermatology and the Discipline of Telemedicine, Faculty of
Medicine (USP) developed the project Telemedhansen (MIOT et
al, 2005).
3.1 Telemedicine: A solution to the interior
and periphery of cities in Brazil?
Authors such as Smith et al (2005) suggest that telemedicine may
be one solution for producing high-quality medicine in places
where the distance from large urban centers is a barrier and also
where there is lack of human resources, financial and physical
resources to construction of clinical expertise.
Recently a group of Brazilians has produced articles showing
how ICTs have been developed and reducing the production costs
of equipment and software, especially at low costs to monitor the
heart rate - the electrocardiograph (ECG). The software
developed can be used in low-cost computers to measure heart
rate in cases of cardiac dysfunction, and especially patients who
have suffered recent myocardial infarctions (PIMENTA CURY et
al, 2005).
Estimates suggest the use of telemedicine generates cost savings
in an amount significantly higher than the costs of implementing
the technology. In a scenario of scarcity of resources is necessary
to create models which have wider coverage and lower cost.
Thus, telemedicine could be one of the best solutions for access
to health services and preventive diagnosis, care professionals
with better technical quality and reduce transport costs and time
of the citizen (MESSINA et al, 2003).
The project Xingú an Indian tribe located in the state of Mato
Grosso, for example, we create and implement a care model for
health monitoring and assistance of health professionals who
provide assistance to the Xingu Indigenous Park. A major goal
was reducing the time of diagnosis, especially of women.
According to Lopes et al (2005), it is essential to develop a
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 technologies
ICTs have had significant development, with a range of
applications and software created and used extensively for
various purposes. The area of mobile technologies is also being
developed and may be involved in telemedicine projects in the
area of social assistance for the quality of care, provision of
services and productivity of teams is enhanced and improved.
The Brazilian health project called the Family Health Program
(FHP) attempts to implement a strategy of refocusing the health
care model for the design of preventive health, operationalized
through the establishment of multidisciplinary teams in primary
health care units. The teams are responsible for the monitoring of
a set number of families, located in an area. The teams operate in
shares of health promotion, prevention, recovery, rehabilitation
of diseases and disorders more frequent maintenance and health
of the community. (BRAZIL, 2009)
An interesting strategy would be to research the use of
technology, application and work in the FHP service to the
citizen and the evaluation of its impact on primary health care.
The introduction of techniques and equipment used in
telemedicine can become a mechanism for ongoing care to
prevention, diagnosis and treatment of the poor.
The use of Internet technology called "3G" (third generation of
internet) could be used by cellular models of "smart"
(smartphones), for collection of movies, photos, conditions of
housing, sanitation, etc..
In the state of Ceará, Northeast Brazil, there is an interesting
project developed a network consists of three Faculties of
Medicine of the State. The network came by the technical
cooperation between the State Health Secretariat of Ceará and
the School of Public Health, the state responsible for the
administration of the PSF. Currently the project aims to train
teachers and students of design and education professionals in
the medical and public health involved. There is also great
interest in studying methods to prevent and improve the
diagnosis of some diseases such as malignant neoplastic
diseases, cardiovascular diseases and infectious diseases, the
ultrasonographic assessment of high risk pregnant women and
mental health, and skin diseases (OLIVEIRA, 2004).
3.3 Telemedicine and costs in Public Health
Costs in health are experiencing an upward trend, due to
democratization of access to the Brazilian health system and also
the expensive prices and values of goods and services in the
world market due to the own demand. This has been the
difficulty with which to finance these costs is leading service
providers, donors, health authorities and the users are
increasingly concerned with the cost of health services and its
consequences on the quality of those services.
Telemedicine can be an interesting way to avoid waste of
resources and to enhance the efficiency of public social policies.
Examples of increased efficiency and decreased costs are
observed in some countries that have implemented a
telemedicine. Recent studies show that in England, 17% of
patients with burns were conducted via telemedicine monitoring
through videoconferencing.
1000 The number of contacts between large medical centers and
the country reduced the emission of carbon dioxide by 39 tons
per year, from trips that patients should be done to achieve the
same query performed without the use of telemedicine (Smith et
al , 2007). In the UK believed to have reduced by 20% the total
emission of carbon dioxide annually, from the burning of fossil
fuels to displacement of patients and health teams
(PATTERSON, 2005). Brazil can use the technique to reduce
costs and carbon dioxide emissions from travel and travel for
patients and health teams.
The sustainability of telemedicine in a hospital, observed in
recent studies that suggest that telemedicine, as well as reduce
costs, 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 provide
an operating system of medical collaboration to exchange
messages and medical files, using free software. The main
reasons for introducing this software is the development of
client-server in health care only to collect information for the
area, facilitating the interaction of professionals and improving
the 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 low
cost and very universal access in Brazil.
Some researchers support the idea of using the second opinion as
one of the approaches to telemedicine, as shown improvement in
the quality of diagnosis and reducing the time used for the
certification 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 Considerations
The growth of technological innovations in computing, high-
resolution digital images, robotics and Internet had a major
impact on how the information is now available in medicine.
Telemedicine has become an important factor in the care of the
patient and has been used increasingly to provide care and
education (DEMIRS, 2003).
Telemedicine should be considered a model of health care with
the potential to offer high-quality medicine to the isolated
populations without access to health. Moreover, it serves as
important tool in the teaching of medicine, by offering an
effective 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 the
graduate and continuing medical education of health
professionals.
Although the proportion of doctors trained in Brazil is close of
the recommendations highlighted by the World Health
Organization (WHO, 2009), the geographical distribution has
lack in some areas and substantial concentration in large urban
centers. The government has emphasized efforts to programs for
primary care, given the social reality, as the case of the Family
Health Program (PSF) and the internalization of the Work
Program in Health (PITS), besides increasing the quality and
infrastructure of National Research Network (RNP) and the
Telemecidicine University Network (RUTE).
However you should understand that telemedicine should be
encouraged by the government. According to Lopes et al (2005),
the correct diagnosis is made in 55% of cases, only the patient's
clinical history. The chances of success increased by 20% with
the implementation of clinical and more 20%, from additional
tests.
So if the technology can expand the scope for adjustment of the
traditional model of medical diagnosis of a low cost with
increased productivity and coverage, you should walk a path of
investment and encourage researchers from all areas to improve
the public health service through the targeting of efforts on
multidisciplinary characteristic of telemedicine.
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