Telehealth in Primary Healthcare: An Analysis of Belo Horizonte's Experience

Characteristics of the Bhtelehealth Project

Belo Horizonte is a city that has 2.45 million inhabitants, with a Family Health Program (Programa de Saúde da Família [PSF]) structure offered by the public system, which covers 72% of the population. There are 504 family health teams working with primary healthcare and each team has one doctor, one nurse, two nurse auxiliaries, and six community health agents. The telehealth model was established with a focus on primary healthcare and was created out of the need for dealing with two central questions in SUS: the establishment of permanent human resources involved with PSF and the burden of services offered in the secondary care network.

The model formatted with these characteristics was financed by the @lis project of the European Community, by the Ministry of Health of Brazil, and by SMSABH and connects academic learning centers of the Universidade Federal de Minas Gerais (UFMG) with basic health units (Unidade Básica de Saúde [UBS]). The main activities of the telehealth project include permanent education through videoconferences and assistance support through teleconsultations, utilizing on-line technology for the more complex cases and off-line for the less-complicated ones. The structure of the multicast network took into consideration the need for the simultaneous transmission of discussion of clinical cases to several UBS. In order for this to be carried out, it was essential to adopt multipoint videoconference software.

Software for the management of teleconsultations was developed and it contains tools that facilitate the process of giving a second medical opinion and consultation. The educational videoconferences have occurred twice a month in the areas of medicine, nursing, and dentistry.

The UBS also have a digital electrocardiogram (EKG), which sends medical exams to a main EKG unit at the Hospital das Clínicas/UFMG. Cardiologists present their opinion on the EKG and send them to basic health units.

The SMSABH has also structured itself to incorporate the recent developments in education that involve organic modeling and animation in distance learning courses. This process occurred in partnership with the Center for Technology in Health at the School of Medicine–UFMG. These courses have greater value because they use platforms of distance learning with videos, animation, and 3D organic modeling.

Courses associated with the needs of the service were created and tested in the technological structure already available—a network of 128 kilobits per second. In this network, one can find an electronic report, a system regulating specialized consultations, and distance learning courses with 3D in a manner that intends to adapt itself to the reality of the public network.

In Belo Horizonte, two distance learning courses were created: the electrocardiogram course and the urgency and emergency course. The former is offered mainly for the professionals of the PSF, who worked with the implementation of digital electrocardiograms at the health units.

Analysis of the Results Obtained with the Bhtelehealth System

The system is already set in 148 UBS. Below are the results obtained during the deployment of the BHTelehealth project in basic care in three areas: medicine, nursing. and dentistry (Table 1). There have been 264 professionals trained in the electrocardiogram distance learning course, and many other primary healthcare professionals are being trained in the urgency and emergency course.

Several research groups evaluated the BHTelehealth project. The Healthcare Network project from @lis of the European community established an evaluation of the BHTelehealth project involving institutions from five countries. ¹ This study considers that the adhesion to the BHTelehealth project is significant given that it involves one out of five professionals of higher education at the UBS. The study emphasized that the innovative elements introduced by the technology are not only related to the context of the courses but also to the learning dynamics, where the feeling of belonging to a virtual community plays an important role. Individuals involved in this process learn about their abilities not only through interjection in the group but also as a result of the efficiency of the innovative practices. Further, it is this group which presents itself as the interlocutor in the videoconferences and proposes the creation of an identity within the work community. This same group strengthens itself through mechanisms of esteem and acceptance of new assistance practices. The feeling of belonging to a virtual community creates the basis for the consolidation of learned skills in the team.

The Pontíficia Universidade Católica de Minas Gerais used focus groups for the analysis of the project, considering that the initiative could be recognized as a technological innovation. ² According to the Diffusion of Innovations theory, ³ one is dealing with a social construction that can consolidate itself according to the adhesion of individuals and groups involved in a social–technical perspective. The project is understood as an “informational regime” ⁴ with specific characteristics, resulting from the interactions among actors including SMSABH, UFMG, and UBS. Within this network, people are constantly communicating and exchanging ideas and opinions. Ultimately, they end up influencing each other and permanently establishing a relationship with the program.

Nonetheless, the analysis also highlights difficulties related to communication, which can make the system's users feel as if they are not a leading actor in the process. This fact can be explained by the lack of training offered in how to use computers and/or technology, creating a cultural barrier for the use of telehealth tools. Many professionals prefer not to solicit teleconsultations to prevent their colleagues from being exposed. This situation still presents itself as a challenge for the incorporation of more significant information and computer technologies in the professional's work trajectory and the improvement of communicational procedures needed to guarantee both the providers' and consumers' full adhesion. The advantages of the project relate to the fact that it can bring to light problems not perceived beforehand, particularly in relation to daily practices, and emerging questions that affect the health professionals.

UFMG, in a quantitative study, ⁵ used 360 semistructured questionnaires to evaluate the videoconferences and the teleconsultations carried out in the BHTelehealth project. It concluded that the teleconsultations impacted assistance and were useful for solving clinical cases and therapeutic procedures as well as for qualifying diagnoses and adequate propedeutics.

The School of Medicine at UFMG conducted qualitative studies on the project. To analyze the perception of the professionals, ⁶ the analysis relied on the methods of discourse analysis and context techniques and the Qualitative Data Analysis-Weft software. This evaluation pointed out several positive elements related to the individual dimension including the incentive for actions, the relative ease of reaching a diagnosis, which helps solve clinical cases, and the knowledge transfer between the doctor from the basic health unit and the specialist. Some of the negative aspects highlighted include the difficulty of the professional admitting the need for a second opinion, the desire of the patient to be referred to a specialist, and the patients' frequent request to not be consulted by the professional from their USB because of feeling insecure about eventual procedures. Some patients prefer to have a conventional appointment with a specialized doctor, rather than having their case submitted to a virtual consultation.

With regard to the organizational aspect, the study highlights the quality of the teleconsultants and the ability and speed to diagnose a case as positive aspects. The negative aspects are related to the incompatibility of daily schedules with the actual teleconsultations. With regard to the technological component, the study lists the fast incorporation of technologies as a positive aspect, whereas the problems related to connectivity weigh in as a negative aspect. The study concludes that despite all these obstacles, there is a capacity to produce benefits for the patient, including qualified attention, resolution of clinical cases, and avoidance of referrals to specialists in the majority of the cases.

In another qualitative study, the reports of the specialists were analyzed. ⁷ A reading of the teleconsultations revealed that the professionals attributed greater value to the job because of access to innovative technologies, the permanent network of exchange with universities, and the interaction between primary and secondary care, which helps with diagnoses and increases resolution.

This group of evaluations already illustrates the progressive impacts the telehealth project in primary healthcare can bring to healthcare services. In practice, the experience of the BHTelehealth project allowed for the following outcomes: the structuring of a wide network of permanent training, through daily assistance problems; better resolution in primary healthcare; a contribution to the structuring of the system in an integrated and hierarchical manner; the use of technology that is not very complex; and the strengthening of ties between the academic environment and health assistance professionals.

However, some negative aspects were also identified, such as the need for introducing a new instrument for creating changes in assistance, requiring, in turn, an important effort in terms of restructuring the work process. The incorporation of technology occurs slowly, as there are scheduling problems with both the coordinators and professionals from primary healthcare. Some of these problems are particularly related to specific activities of the project such as finding time in the professional's schedule, the elaboration of schedules/timelines for participating in teleconsultations and videoconferencing, and the internal communication of the project's activities.

The Value of Incorporating Telehealth Resources in Primary Care Units

The establishment of health systems based on primary care units leads to less spending on health, impacting the morbimortality in different social realities. The increasing expenditures in health and the growth of the population have resulted in the convergence of a primary healthcare agenda with two directions.

The first direction reflects the WHO's reaffirmation of the Alma-Ata values, setting the need for changes in the structuring of health systems. These changes constitute an agenda of primary healthcare renovation. ⁸ According to the WHO, the needs and expectations of the population create the impetus for this renovation, which would not only make the services more socially pertinent and more sensitive to the changes occurring worldwide, but would also create better results.

The second direction reflects how the agenda of primary healthcare was appropriated by more restricted functional models as a reflection of the liberal-private approach. The models included selective service packages organized according to the World Bank's perspective of primary healthcare. These services were destined at poor countries, reflecting both a managerial logic and strong emphasis on the control of costs.

This process gained strength in the 1990s, having influenced the very format of health systems. Later on, particularly in Europe, new initiatives were implemented with the intention of restructuring basic care. These changes fostered improvements particularly in the quality and efficiency of primary healthcare. ⁹ First, it established greater power and control of primary healthcare over providers of other levels of attention, and second, it expanded the function and services offered at the first level, amplifying the role of provider.

In Brazil, the reorganization of the health system, focused on primary healthcare, has already produced significant results. The establishment of the PSF seeks to organize the activities of patient care, by becoming the coordinator of the other levels of the system and conforming to the strategic sustainability for SUS. ¹⁰

The creation of the BHTelehealth Project, which was founded to support the staff of PSF with regard to both assistance support and permanent education, has reinforced the central role of primary healthcare. In practice, BHTelehealth connects the basic health units to the units of UFMG in the areas of nursing, dentistry, and medicine. It allows professionals of PSF to discuss clinical cases with professors.

Hence, the incorporation of telehealth in the municipal network of Belo Horizonte provides the professionals of primary healthcare the access to specialists when there is a need for discussing clinical cases. In addition, it gives them absolute control over the choice of care for patients, allowing the basic care professional the control of access to specialists. This further allows the professionals the possibility of choosing between continuing to care for the patient or referring the patient to another professional. This increases a professional's scope of duties within the sector of services offered in primary healthcare. Different from managed care, the BHTelehealth project sets itself apart given its place in creating productive processes and through the decentralization of work in health. ¹¹ The BHTelehealth project seeks to add new possibilities of support for clinical decisions in primary healthcare through shared experiences with other assistance levels. Further, it qualifies this level of attention and improves the capacity of control of referrals in relation to secondary care because it works along with propedeutic activities under the control of primary healthcare. In this sense, the relationship becomes inverted: the levels of greater complexity contribute to placing a patient in primary healthcare, and when this action is decentered through referrals, it already occurs within the framework of assistance.

The incorporation of telehealth resources includes the following aspects:

It strengthens the role of primary healthcare in terms of coordinating patient attention. This occurs when the professionals are more informed after discussing each case. As a result, they only refer patients who effectively cannot be assisted in primary healthcare. It also coordinates a new manner of offering service through the shared evaluation for entrance to other complex levels and by contributing to the structuring of effective and integrated networks. It gives primary healthcare staff a powerful arsenal of up-to-date information regarding specific cases and fosters greater power of clinical intervention;