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The telemedicine at Brazilian Public Policy Management

Ricardo Matheus Manuella Maia Ribeiro


University of São Paulo – USP – Brazil University of São Paulo – USP – Brazil
Araújo street, 124. São Paulo – SP – Brazil Araújo street, 124. São Paulo – SP – Brazil
+(55)11 7227-7521 +55(11) 7633-1678
ricardomatheus@gmail.com maiamanuella@gmail.com

ABSTRACT an enormous range of possibilities for collaborative services in


very remote regions (WHITTEN & HOLTZ, 2008th).
The paper analyzes positive and negative effects of the
Among them, the use of telemedicine between the areas of
introduction of a broad public health policy based on
radiology and dermatology (Soirefmann et ali, 2008) where the
telemedicine. From the main concepts and definitions of
routing of scanned images of X-rays and computed tomography
telemedicine should be analyzed the models used worldwide in
of distant places or difficult access shows that the quality of X-
the development of this tool of medicine that helps in education,
ray original is as good as the copy sent to the center showing the
reduction of costs and technological support to other areas of
effectiveness and accuracy of teleradiology (O'SULLIVAN et al,
social policies. Best practice in telemedicine will be described in
1997). Other uses are more familiar: videoconferencing,
its role in reducing costs of health, minimizing the environmental
collaborative work and cases studies, distance education and
impact of human activities and generate innovation that
continuous specialization, the update in the area of professional
encourage citizenship and education.
training and the second opinion, beyond the consultation online.
Categories and Subject Descriptors However, there are authors who suggest other uses for
Management telemedicine, in addition to the employment of high technology
and its high costs. The use of the called ‘low technology’ and its
General Terms low level of complexity and costs should avoid the problem of
Management and Theory. 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
Keywords with the brazilian scenario of the internet infra-structure, this
Telemedicine; Brazil; e-governance; e-government; Public paper believes the public policy of telemedicine in Brazil should
Health. use the low technology to improve all the country, including
areas that cannot have the access of high technology, such as the
1. Introduction high connection cable of internet, in contrast of the widespread
According to World Health Organization (WHO, 2009), to cover use of the dial-up connection, an example of low technology.
the provision of telemedicine services to health care is generally The Telemedicine University Network (RUTE) indicates that the
used where the distance is a critical factor. In general, these Brazilian shares in telemedicine have been conducted since the
services are provided by health professionals that use of 1990s, however, still quite limited. A country with continental
information and communication technologies (ICTs) for the dimensions, however, it can benefit greatly with the formation
exchange, development and continuing education for providers of and strengthening of collaborative networks of integrated care at
health services, and to complete surveys and evaluations. a distance. Benefits such as cost reduction in transportation and
Significant portion of medical specialties has been using ICTs for communications and the possibility of introducing a medical
the development of medical practice in the distance. The specialist in remote regions of the country (RUTE, 2009).
adoption of telemedicine has occurred in the same proportion of According to resolution 1643/2002 of the Federal Council of
the development of these technologies for communication and Medicine (CFM), in Article 1, the definition of telemedicine is
information, affecting the form of medical approach and creating 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
Permission to make digital or hard copies of all or part of this work for definitions of telemedicine are also distributed in the American
personal or classroom use is granted without fee provided that copies are not Telemedicine Association (ATA), where telemedicine is defined
made or distributed for profit or commercial advantage and that copies bear
this notice and the full citation on the first page. To copy otherwise, to
as the use of medical information conveyed from one place to
republish, to post on servers or to redistribute to lists, requires prior specific another by means of electronic communication, to health and
permission and/or a fee. education of patients and the medical professional for assistance
ICEGOV2009, November 10-13, 2009, Bogota, Colombia in improving health.
Copyright 2009 ACM 978-1-60558-663-2/09/11… $5.00 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 Some advantages that telemedicine can provide to users,
of cases worldwide in which telemedicine is a simple routine use professionals and, mainly, to the government or entity that you
of the tools of information technology and telecommunications, choose for your use:
for a means to achieve goals such as education for citizens, aid in 1. Reduction of costs of transportation of patients;
inhospitable places or at critical junctures such as natural
disasters. 2. Expansion of access to health, focusing particularly the
use of technologies for large;
These definitions, which cover more purposes for telemedicine,
in addition to the basic processes proposed by the organizations 3. Human resource development of health in Brazil;
studied the relationship between patients and professionals in the 4. Easier, faster and more accurate information and
health area, where there is usually a big obstacle as distance, clinical history of the patient;
lack of professional and critical moments, such as floods and
5. Videoconference to obtain second opinions and advice
natural disasters.
from experts;
2. Objectives of Telemedicine 6. End of lines through the booking system;
The main objectives of telemedicine can be divided into high and 7. Rationalization of resources for the health of patients
low use of technology in ICT. Examples of high-tech appliances through triage
are more modern and thus more expensive, of which only a
portion of the population have access. Broadband is a technology 8. Reduction of space for the storage of data users;
of the telemedicine service that is not yet widely distributed in 9. Standardization of conduct and quality of care;
Brazil, for example. Alternatively, low ICTs are technologies that
10. Possibility of increased scientific studies through the
are more widespread, cheaper and with full access population. In
selection of cases for the production of research on
Brazil, the Internet dial can be in all the regions.
specific cases or cohort;
One of the main goals of telemedicine is to study low-cost
However, as with any new process, there are still some
technologies that have technical and social in accordance with
disadvantages involving the use of telemedicine, such as:
the social scenario of most of Brazil's territory. The low
technologies such as telephone and internet dial-up connection • Lack of professionals with licenses to perform medical
can be widely adopted, favoring the majority of the population, procedures;
without major investments in technology too expensive that have • Important changes in the doctor-patient relationship;
great loss of the depreciation as new products are launched.
• Possibility of technological failures;
The universalism of procedures and technological resources
should be adopted to improve the collection, processing, analysis • Implementation can be slow and lack of standardization,
and use of information, such as through the introduction of especially in large and complex national projects;
computers in the health sector with efficient and affordable cost • Patient loses individual properties and social becoming only
or using the cellphone which physicians can update patient’s the number and clinical characteristics at the expense of their
information and consult information about his historical. For this individuality;
policy is necessary a central data bank and wi-fi internet for the • High cost of telemedicine (equipment, technology, expert
doctors that are working online, updating and consulting
staff in the maintenance of equipment, training of staff);
information about patients.
• Possibility of misinterpretation of data and images
In summary, the main goals of telemedicine are: transmitted, depending on the quality of the equipment and
1. Reducing transfers, time and cost of transporting the sample sent.
patients;
• Need to spend training of Human Resources (HR);
2. Improve the management of health resources by
• Lack of security and confidentiality of electronic information.
evaluating and sorting by experts, reducing the
Ease of access to records and trouble criptogração data and
pressure on hospitals;
• Possibility of delegation of responsibility for medical or other
3. Strengthen cooperation and integration of researchers
health professionals by person not qualified.
with the sharing of clinical records;
4. Allow the process to experts fast in case of disasters 2.1 The use of ICTs and the Rights of the
and emergencies; Citizens
5. Increase the amount of educational programs for The use of ICTs, currently facing struggles for social
physicians and residents located in areas outside of and historical transformations that characterize the movements of
specialized centers; implementation of the other natural rights. The institutional
construction occurs through political and economic disputes and
6. Develop technologies for transmission of audio, video
overcome the contradictions between his statement and the
and images in health;
effective implementation simple. The materiality of rights is
7. Build models of information on the Web to improve therefore an object of a dispute within the different segments of
communication and integration of health services.
society and state apparatus, not free of setbacks and advances develop the skills in problem solving and the acquisition of
(VAZ, 2005). technical knowledge (DEMIRIS, 2003).
In the field of telemedicine is no different. You can say that the However, a methodology and set minimum standards are needed
possibilities for promotion of citizenship through the Internet can for the promotion of distance education is carried out
be understood as those that allow for easier access and the satisfactorily, such as institutional support, planning and
exercise of rights. That is, it is possible to establish a typology of structuring the course, communication between students, support
rights that may be impacts of the use of government portals or the student, evaluate and update the program applied (PHIPPS &
websites (VAZ, 2003), including: MERISOTIS, 2000).
• Right to information of particular interest; KELMIS (2007) gives as an example the course of sentinel node
• Right to public services; for prevention, early diagnosis and biopsy of breast cancer in the
virtual environment of learning called Modular Object-Oriented
• Right to own time; Dynamic Learning Environment (Moodle). The course taught for
• Right to be heard by the government; nine students, all graduate students in medical sciences from
different Brazilian states, obtained by continuous access virtual
• Right to social control of government;
participants.
• Right to participation in public management.
The author highlights the importance of planning and schedule
The first three duties are related to the provision of public for the success of similar experiences. It also highlights the need
services and access to individual rights. The last three bind to the for real interest of students, since there is a fundamental factor
exercise of collective rights. However, telemedicine can be that these professionals move to the continuing need to update
sufficiently advantageous to the country and the interests of the the labor market.
whole company out of care and service excellence, using the
A distance education in health care can reduce costs, improve the
premise only the rights to their own time and the right to public
quality of medical and hospital care, reduce the need for high
services through the use of ICTs offered by government to
ratio of medical specialists for people in remote areas, reducing
promote health care and in telemedicine.
the number of deaths and avoid unnecessary expenses with
Every citizen should be entitled to their own time. While in large diseases whose diagnosis and treatment follow well established
cities easy access to health services and better quality, more patterns.
people lacking financial resources and in worse health status,
needs to lose a lot of time to move up to the health units of 2.3 The Preventive telemedicine and the
excellence. Technologies included in an essential public service Citizen Education
such as health, may help to reduce inequality and provide more For decades it is known that education can promote cost
time for the right people. The right to public service is a basic reduction, improved quality of life and provide better levels of
right, provision of the Federal Constitution, so the quality of care human development in the country (SCHALL et al, 1987). The
in Brazil must cover the entire population of the country. Well as use of telemedicine as a form of preventive medicine and citizen
health, education is one of the rights of Brazilian citizens, and education, and in the way of the Program Young Doctor (2009),
another area in which telemedicine can act to provide access to in the state of São Paulo and the lower Amazon River region
public education in health. should be encouraged.
2.2 The Telemedicine like a tool for the 3. The Telemedicine in Brazil
education The growing demand for specialized medical care and training of
Brazil may have the telemedicine as a support for education and personnel in public health, it is justified and appropriate to the
training of human health resources in regions that access to development of work with telemedicine (OLIVEIRA et al, 2004).
infrastructure, public education is hardly difficulted. The use of Among the key initiatives and projects implemented in
the infrastructure of telemedicine ICTs used in diagnoses and telemedicine in the country, there are Telederma project,
therapeutics while they are not being used can improve the National Project Stocks Permanent Control (ANAPEC).
education in this regions without human health resources in One of the first experiences in teledermatology in Brazil was the
abundance. The education of health professionals via internet Telederma project, involving the department of dermatology at
with classes for graduate and expertise, through distance the Hospital das Clinicas (UFRGS) and Discipline of
education, can be a good solution for the lack of certains Telemedicine, Faculty of Medicine (USP). The Telederma
professionals, the improvement of the professional quality of the included, in addition to an efficient system for dermatological
physicians and all the human health resources of the health interconsultation internet, educational support by mailing list,
system, such as nurses and others professionals. classroom teaching, diagnostic guidelines, drug interaction and
The distance education is the teaching-learning process, support for epidemiological surveillance system (MIOT et al,
mediated by technology, where teachers and students can be 2005).
separated spatial and/or time (Moran, 1994). One of the The procedures for the consultation was carried out by residents
proposals addressed to specialization and continuous who, photographed 71 patients of the dermatology clinic and the
improvement of Rh in the tele-health is distance education, clinical information entered on the form of the system. Some
through teleconferences and tutorials. The problem-based teachers in a room adjacent to evaluate patients via Internet, and
learning (PBL) allows the student to use cases as the stimulus to
later live. The percentage of accuracy in diagnosis was 91.5% in was reducing the time of diagnosis, especially of women.
remote clinical evaluations and 95.8% in the presence ratings, According to Lopes et al (2005), it is essential to develop a
which showed statistically insignificant difference between the system on internet radio at low cost to facilitate the activities.
methods of diagnosis (CHAO et al, 2003c).
3.2 The telemedicine, The Programa Health of
Another concept developed to promote health is the ANAPEC
which included actions to control health strategies disseminated family and the use of mobile technologies
using telemedicine, to connect centers of reference and research ICTs have had significant development, with a range of
assistance to the health units (at different levels), providing applications and software created and used extensively for
continuous care and support training of participants involved, as various purposes. The area of mobile technologies is also being
well as formation of task-forces (including paramedics) for developed and may be involved in telemedicine projects in the
education and early detection of diseases (CHAO et al, 2003b). area of social assistance for the quality of care, provision of
services and productivity of teams is enhanced and improved.
The integration of various centers to allow maintenance of a
system of continuing education, and support high quality The Brazilian health project called the Family Health Program
diagnosis of creating a network of national scope for education, (FHP) attempts to implement a strategy of refocusing the health
referral of cases (telescreening) and second medical opinion. care model for the design of preventive health, operationalized
ANAPEC proposed the use of various technological resources - through the establishment of multidisciplinary teams in primary
from the internet by dial up line of videoconferencing systems, health care units. The teams are responsible for the monitoring of
depending on the local solution to be viable (MIOT, 2005). a set number of families, located in an area. The teams operate in
shares of health promotion, prevention, recovery, rehabilitation
The project presents ANAPEC create, in parallel, means for
of diseases and disorders more frequent maintenance and health
deploying a network targeted to the detection and diagnosis of
of the community. (BRAZIL, 2009)
leprosy. The training offered to professionals without medical
degrees would be done with the technology of distance education. An interesting strategy would be to research the use of
These actions could contribute to combating and elimination of technology, application and work in the FHP service to the
leprosy, as an aid to a greater number of persons trained and citizen and the evaluation of its impact on primary health care.
qualified to undertake the work, the suspected cases would be The introduction of techniques and equipment used in
discovered and treated more quickly. Therefore, the Department telemedicine can become a mechanism for ongoing care to
of Dermatology and the Discipline of Telemedicine, Faculty of prevention, diagnosis and treatment of the poor.
Medicine (USP) developed the project Telemedhansen (MIOT et The use of Internet technology called "3G" (third generation of
al, 2005). internet) could be used by cellular models of "smart"
(smartphones), for collection of movies, photos, conditions of
3.1 Telemedicine: A solution to the interior housing, sanitation, etc..
and periphery of cities in Brazil? In the state of Ceará, Northeast Brazil, there is an interesting
Authors such as Smith et al (2005) suggest that telemedicine may project developed a network consists of three Faculties of
be one solution for producing high-quality medicine in places Medicine of the State. The network came by the technical
where the distance from large urban centers is a barrier and also cooperation between the State Health Secretariat of Ceará and
where there is lack of human resources, financial and physical the School of Public Health, the state responsible for the
resources to construction of clinical expertise. administration of the PSF. Currently the project aims to train
Recently a group of Brazilians has produced articles showing teachers and students of design and education professionals in
how ICTs have been developed and reducing the production costs the medical and public health involved. There is also great
of equipment and software, especially at low costs to monitor the interest in studying methods to prevent and improve the
heart rate - the electrocardiograph (ECG). The software diagnosis of some diseases such as malignant neoplastic
developed can be used in low-cost computers to measure heart diseases, cardiovascular diseases and infectious diseases, the
rate in cases of cardiac dysfunction, and especially patients who ultrasonographic assessment of high risk pregnant women and
have suffered recent myocardial infarctions (PIMENTA CURY et mental health, and skin diseases (OLIVEIRA, 2004).
al, 2005).
3.3 Telemedicine and costs in Public Health
Estimates suggest the use of telemedicine generates cost savings
Costs in health are experiencing an upward trend, due to
in an amount significantly higher than the costs of implementing
democratization of access to the Brazilian health system and also
the technology. In a scenario of scarcity of resources is necessary
the expensive prices and values of goods and services in the
to create models which have wider coverage and lower cost.
world market due to the own demand. This has been the
Thus, telemedicine could be one of the best solutions for access
difficulty with which to finance these costs is leading service
to health services and preventive diagnosis, care professionals
providers, donors, health authorities and the users are
with better technical quality and reduce transport costs and time
increasingly concerned with the cost of health services and its
of the citizen (MESSINA et al, 2003).
consequences on the quality of those services.
The project Xingú an Indian tribe located in the state of Mato
Telemedicine can be an interesting way to avoid waste of
Grosso, for example, we create and implement a care model for
resources and to enhance the efficiency of public social policies.
health monitoring and assistance of health professionals who
Examples of increased efficiency and decreased costs are
provide assistance to the Xingu Indigenous Park. A major goal
observed in some countries that have implemented a
telemedicine. Recent studies show that in England, 17% of centers. The government has emphasized efforts to programs for
patients with burns were conducted via telemedicine monitoring primary care, given the social reality, as the case of the Family
through videoconferencing. Health Program (PSF) and the internalization of the Work
1000 The number of contacts between large medical centers and Program in Health (PITS), besides increasing the quality and
the country reduced the emission of carbon dioxide by 39 tons infrastructure of National Research Network (RNP) and the
per year, from trips that patients should be done to achieve the Telemecidicine University Network (RUTE).
same query performed without the use of telemedicine (Smith et However you should understand that telemedicine should be
al , 2007). In the UK believed to have reduced by 20% the total encouraged by the government. According to Lopes et al (2005),
emission of carbon dioxide annually, from the burning of fossil the correct diagnosis is made in 55% of cases, only the patient's
fuels to displacement of patients and health teams clinical history. The chances of success increased by 20% with
(PATTERSON, 2005). Brazil can use the technique to reduce the implementation of clinical and more 20%, from additional
costs and carbon dioxide emissions from travel and travel for tests.
patients and health teams. So if the technology can expand the scope for adjustment of the
The sustainability of telemedicine in a hospital, observed in traditional model of medical diagnosis of a low cost with
recent studies that suggest that telemedicine, as well as reduce increased productivity and coverage, you should walk a path of
costs, it also creates opportunity for expanding the productivity of investment and encourage researchers from all areas to improve
services to the population (MEDEIROS & WAINER, 2004). the public health service through the targeting of efforts on
For example, the MedMail Project has the objective to provide multidisciplinary characteristic of telemedicine.
an operating system of medical collaboration to exchange
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