Teleconsultations in Public Primary Care Units of the City of Belo Horizonte,Brazil: Profile of Patients and Physicians

Abstract

Objective: The aim of this study is to report patient and physician profiles of those who used the teleconsultation system in the primary care health units of a health district in the city of Belo Horizonte, MG, Brazil. Materials and Methods: Data were collected from the telehealth attendance records of nine Primary Health Units (Unidade Básica de Saúde [UBS] in Portuguese) and from interviews carried out with the referring physicians. The criteria for inclusion required that data come from users seen by means of telehealth in the period between December 2004 and August 2010 and from the practitioners who saw them. The following were excluded: physicians who were not working in the UBS when the data were collected and a physician who did not agree to take part in the study. Results: Two hundred sixty-three teleconsultations were analyzed, and 20 referring physicians were interviewed. The offline method was the most common. The physicians were predominantly female and had graduated over 11 years ago. The patients were predominantly adult women. After teleconsultation, a prescription was not necessary for 9.8% of patients. When required, 83.2% of the medication was available in the UBS. In 68.3% of cases, additional tests were required. The incorporation of these technologies prevented the physical referral of patients in 64.2% of cases. Conclusions: Telehealth resources can help to improve the provision of primary healthcare, reducing the number of physically referred patients. The number of teleconsultations is still small, and there is a need to encourage physicians to use the system.

Introduction

Modern Brazil has been making great progress and seeing significant improvements in issues relating to the health of its population. Following the 1988 Brazilian Constitution,¹ in particular the provisions of article 198 regarding the creation of a National Health System (Sistema Único de Saúde [SUS] in Portuguese), it is clear that there is still a lot of work to be done for the principles that guide this system to be consolidated and provide even better results. The SUS is seen as a system with a solid base that allows the expansion of healthcare access for a wider population, without, however, having become a system capable of breaking down the healthcare inequalities that are so frequent in the numerous regions of Brazil. There is still a lot of work to be done to achieve the objective of providing the Brazilian population with improved healthcare. One of the key points in this area lies in meeting the challenge of providing the healthcare system with a greater problem-solving capacity, thereby effectively intervening in the current healthcare situation in the country.²

A proposal that can help to overcome this challenge is the incorporation of telehealth. This resource marks a change in traditional methods of offering healthcare by seeing the development of techniques to offer distance healthcare.^3,4 The practice of telehealth represents the emergence of a new paradigm that aims to improve the conditions of healthcare users in developed and underdeveloped countries. This tool allows the provision of services for a population that needs increased access to specialist physicians,⁵ mostly teleconsultation.⁶

Telehealth represents an excellent option in terms of providing healthcare services to residents in remote areas because it emerges as a tool with the capacity to help solving problems, and it manages to join several remote places and allows interaction between people in these different places. Consequently, reference centers can be connected with basic health units in isolated areas, can provide support when there are any doubts when diagnosing a case, guide clinical decision making, and promote distance learning.^7

–12

Care and follow-up of patients who receive either conventional or telehealth treatment can both be carried out using the teleconsultation system, without requiring a specialist to provide on-site supervision.¹³ It is believed that with the information empowerment of health services, there will be an improvement in the communication and the effectiveness of cross-referencing that will help to further guarantee the quality of continuous healthcare.¹⁴ There are still gains that can be made with this practice, and new research needs to be carried out to identify how this can be done.^15
–17

The Belo Horizonte-Telehealth (BH-Telehealth) Program was developed in the Primary Health Unit (Unidade Básica de Saúde [UBS] in Portuguese), leveraging technology available from the implementation of an electronic medical record. Some activities have been developed, gradually, such as Web-based conferencing, distance learning courses, and electrocardiogram transmission and teleconsultations. In some aspects the UBS system is not yet fully deployed. The number of patients seen by health professionals per day is large, and there is still no management awareness that allows a greater number of teleconsultation requests. When this does occur, the most frequently requested mode is offline because the online mode requires greater expenditure of time by the health professional.⁶

The aim of this study is to report patient and physician profiles for those who used the teleconsultation system in the primary care health units of a health district in the city of Belo Horizonte, Brazil.

Materials and Methods

A transverse study was carried out in the UBS for the central-south healthcare district of Belo Horizonte. Quantitative methodology was used through the application of a structured questionnaire.

The study was based on the survey of the organization of the primary care units and the telehealth implementation in the city. The Belo Horizonte City Health Department (Secretaria Municipal de Saúde [SMSA-BH] in Portuguese) already has a structure in place at the UBS where telehealth resources are available for providing healthcare and educational support.⁶ There are 147 UBS spread over nine health districts. These units are integrated as part of the structural network of the BH-Telehealth project, implemented in Belo Horizonte since 2004.^6,18

A survey carried out until July 3, 2009, revealed that up to that date, 543 teleconsultations had been carried out. Of the nine health districts, the central-south had 267 teleconsultations (49.2%), the Barreiro had 64 (11.8%), the northwest had 60 (11.0%), and the other six districts totaled 152 teleconsultations (28.0%). Given this context, the present study was based on data collected at the UBS of the central-south healthcare district. The initial idea was to collect data from all 12 UBS of that district; however, 3 UBS were not included in the data sampling because one of them specializes in respiratory diseases care, in another one the data were lost, and in one of them information was not yet enabled. Thus, data were collected from the 263 teleconsultations carried out in nine UBS of the central-south healthcare district.

Regarding healthcare, the established criteria for inclusion were teleconsultations carried out in the UBS of the central-south healthcare district between December 2004 and August 2010. Information from the teleconsultations was obtained from the records present in the information management system of the BH-Telehealth, which was made available by the referring physicians using a password and then the information was transferred to the researcher.

The sample analyzed was composed of 20 physicians who carried out teleconsultations. The following were excluded: physicians who were not working in the UBS when the data were collected and a physician who did not agree to take part in the study.

The questionnaire used had a descriptive initial session that addressed issues related mainly to the number of patients seen per day, working hours, working time at the UBS, and the specialty of physicians who requested teleconsultations. Then we sought information pertaining to teleconsultations requested by them, including, among others, patient gender, age, origin, multiple complaints, specialty requested, resolubility of second opinion, and drug prescribed (if any).

The data were systematized and analyzed by SPSS version 18.0 software (SPSS, Inc., Chicago, IL). The study was approved by both the Federal University of Minas Gerais and the SMSA-BH Ethics in Research Committee. Interviewees agreed to provide information for the study by signing the Informed Consent Form (Termo de Consentimento Livre e Esclarecido in Portuguese) and will have their identities kept confidential.

Results

In the fields of expertise available in the UBS, it was observed that the teleconsultations were requested by 13 general practitioners (15.3%) and by 7 internal medicine specialists (8.3%). Assessment within the isolated categories revealed that telehealth use was accessed by 50.0% of the general practitioners and by 33.3% of the medical practitioners.

Analysis of the physicians who used the teleconsultation system in the UBS of the central-south healthcare district is shown in Table 1.

Table 1.

Analysis of the Physicians Who Used the Teleconsultation System in the Central-South Healthcare District (n=20), Belo Horizonte, Brazil, 2004–2010

CHARACTERISTIC	N	%
Sex
Male	5	25.0
Female	15	75.0
Time since graduation
0–10 years	2	10.0
>10 years	18	90.0
Graduated from public or private university
Public	11	55.0
Private	9	45.0
Degree title
Resident/lato sensu	18	90.0
Master	2	10.0
Do you work elsewhere?
No	8	40.0
Yes	12	60.0
Number of patients seen daily in UBS
<12	5	30.0
>12	15	70.0
How long have you worked at the UBS?
0 to 10 years	14	70.0
>11 years	6	30.0
Was there a change in professional performance after teleconsultation?
No	7	35.0
Yes	13	65.0
Information technology knowledge
No	1	5.0
Yes	19	95.0
Do you think the equipment (system) is easy to use?
No	7	35.0
Yes	13	65.0
Do you believe that it reduces referrals?
No	4	20.0
Yes	16	80.0

UBS, Primary Health Unit (Unidade Básica de Saúde in Portuguese).

In terms of the number of teleconsultations, the Nossa Senhora de Fátima UBS provided care to the most patients, totaling 31.6% (Table 2). Analysis of the teleconsultations (n=263) carried out at the central-south healthcare district UBS is detailed in Table 3. In 83.2% of the cases, medication was prescribed that was available in the UBS pharmacy, and in 68.3% of the cases, at least one additional test was requested in order to move the case forward.

Table 2.

Teleconsultation Distribution by Healthcare Centers in the Central-South Healthcare District (n=263), Belo Horizonte, Brazil, 2004–2010

HEALTH CENTER	N	%
Carlos Chagas	39	14.8
Tia Amância	25	9.5
Menino Jesus	7	2.7
Nossa Senhora Aparecida	11	4.2
Santa Rita	11	4.2
Nossa Senhora de Fátima	83	31.6
Cafezal	3	1.1
Nossa Senhora da Conceição	71	27.0
Conjunto Santa Maria	13	4.9

Table 3.

Analysis of the Teleconsultations (n=263) Carried Out at the Central-South Healthcare District, Belo Horizonte, Brazil, 2004–2010

VARIABLE	N	%
Type
Online	27	10,3
Offline	236	89.7
Sex
Male	98	37.3
Female	165	62.7
Age group
Children and adolescents (up to 19 years old)	33	12,5
Adult (20–59 years old)	163	62.0
Elderly (above 60 years old)	67	25.5
Medicine available from UBS^a
No	25	9.8
Yes	124	48.6
No prescription	106	41.6
Additional tests requested^b
No	83	31.7
Yes	179	68.3

UBS, Primary Health Unit (Unidade Básica de Saúde in Portuguese).

n=255.

n=262.

The most requested specialty arising from the teleconsultations was endocrinology, which totaled 39 (14.8%) of the teleconsultations, followed by cardiology (12.2%), neurology (9.5%), dermatology (8.7%), hematology (8.4%), orthopedics (6.8%), breast disease (6.5%), nephrology (6.5%), otolaryngology (4.2%), and others (22.4%).

In terms of the referral services, the data revealed that, from a total of 263 teleconsultations, 167 did not require physical referral, meaning that the problem could be solved in the UBS with the use of teleconsultation, resulting in 63.5% resolution.

Discussion

A program entitled “Family Health Program” was implemented in Belo Horizonte in 2002, leading to changes in the organization and operation of UBS. New staff members were hired, and the program sought to strengthen the relationship between patients and health professionals. The BH-Telehealth Program through the use of teleconsultation is considered a great ally in offering support for the continuity of comprehensive healthcare. The teleconsultations allow the patient's problem to be solved in the UBS, reducing referrals to specialty centers and increasing the resolubility of primary care,⁷ contributing to the health system being more effective.^6,18 This study analyzes the profile of physicians and patients using the teleconsultation system, trying to identify problems related to the incorporation of new technologies and seeking a reflection on how to optimize system utilization.

Physician Profile

In this study, the profile of the referring physicians demonstrated a predominance of females, many of whom had graduated over 10 years ago from public universities and whose highest postgraduate degree was medical residency or specialization. The physicians stated that as well as working in the UBS, they also provided services in another center (60.0%), and 70.0% saw more than 12 patients per day. When questioned about prior information and communication technology (ICT) knowledge, 95% said they had prior knowledge. For 65.0% of these physicians, the ICT system used for teleconsultation was user-friendly, and 80% believed the system was safe to use. Regarding the incorporation of technology in primary healthcare, 80% stated that these resources reduce the referral of patients for reference. A survey conducted in Brazil on ICT use showed that the contact with informatics is directly linked to the age of the professionals because the introduction of these social innovations occurs more often among younger individuals.¹⁹

Of all the physicians in the UBS of the central-south healthcare district, there was greatest adherence toward the incorporation of telehealth in primary healthcare by general practitioners (15.3%). These professionals are the first to see patients and then, based on the care provided, decide if referring is required. In the UBS it is possible for them to refer the patients to some specialists, like internal medicine specialists, pediatricians, and gynecologists. There is clearly a need to stimulate the use of telehealth by general practitioners who still do not request teleconsultation. Nowadays all the UBS are information-enabled.

The use of ICT in healthcare can represent a barrier for physicians handling the equipment if they are unfamiliar with simple commands.²⁰ A European experience when incorporating telehealth resources revealed that, as well as having unequal participation from the physicians involved, it was also difficult to change the habits of those who do not believe in the proposal.²¹ This situation can be minimized through technical support offered to physicians in the field of ICT. The SMSA-BH offers logistical support for physicians. During the years of implementation of the BH-Telehealth Program, the system was updated regularly, and many of the problems that had been experienced previously were solved. Currently, access to the teleconsultations portal is faster, but some physicians are still unfamiliar with it. Added to this is that, during the data collection for this study, it was observed that 95% of the referring physicians had ICT knowledge and that 65% considered the system user-friendly.

A large barrier to the use of ICT in healthcare is reflected in the reports of physicians who claimed they lack sufficient knowledge to use the resources and also had difficulties related to the time and effort required to learn to use them, as well as fear of learning.^22,23 We must take into consideration that a physician with a workload of 20 h/week will see around 12 patients per day, whereas a physician working 40 h/week will see more than 20 patients per day. This excessive number of visits, along with the lack of personal space to carry out teleconsultations, makes using these technological resources in healthcare more difficult. The physicians stated that they often carried out teleconsultations after all their visits, which is why they preferred to use the offline method.

Many medical doctors are still resistant to incorporating these new technologies, but it is noteworthy that awareness workshops and seminars were conducted. On the other hand, some primary care physicians were enthusiastic about using these resources. The coordinators of the BH-Telehealth Program have been conducting monitoring and periodic evaluations of the service. Actually, the complicating factors are high demand for care of patients and the lack of availability of in-service time for the doctor to prepare the UBS case and request teleconsultation, thus depending on a political decision from the central-level directors and UBS managers.

Some discussions have been reported in the literature on the behavior of the physician to seek or not to seek a second opinion. Some determining factors are the location and the professional working system,²⁴ the belief that the patient's problem is not serious and does not require a deeper approach,²⁵ and the time available to perform this activity.²⁶

As part of a study carried out in Spain, which produced interesting results in terms of using telehealth, an incentive for online teleconsultation was offered.²¹ There are also reports that the offline method tended to be more common because answers are received more quickly, and it can also be carried out from any computer with access to the Internet.⁶ It was observed in the present study that, of the 263 teleconsultations carried out in the UBS of the central-south healthcare district, 10.3% were online, whereas offline teleconsultations were far more common, totaling 89.7%. It is thought that these results are heavily linked to the difficulties encountered with carrying out online teleconsultations at the beginning of the BH-Telehealth Program because there were technical problems.

Patient Profile

Although women live longer than men, they have a higher morbidity rate and more psychological problems and use healthcare services more frequently.²⁷ In a study carried out in São Paulo, Brazil, that aimed to identify the problem-solving capacity of healthcare services, the authors noted a predominance of women (57.3%) who used healthcare services.²⁸ The data collected in the UBS of the central-south healthcare district of the City of Belo Horizonte support those findings and also reveal that in telehealth there is greater demand for teleconsultations from female users (62.7%).

In addition to the fact that women use healthcare services more frequently than men, these services are also being used more often by children and the elderly.²⁷ No record was found in the literature on increased use of system teleconsultation by female patients. In Brazil, the socioeconomic context indicates the dominant role of women as housewives and in charge of the household duties and child care.²⁹ This fact facilitates a higher frequency of women in the UBS. The data gathered from the UBS of the central-south healthcare district in Belo Horizonte reveal greater use by adults whose age range is between 20 and 59 years old. Brazil is in the third stage of demographic transition (i.e., there are large numbers of children, but the population pyramid shows a decrease in the number of children and an increase in the number of elderly).²⁹ It is worth highlighting that care by telehealth resources was not commonly used in the case of pediatric care. One possible explanation for this finding may be related to the presence of pediatrics specialists within the UBS itself. Yet the elderly, who made up 25.5% of the population receiving care provided by telehealth, represent more complex cases and show a growth in demand for treatment and care for chronic degenerative diseases.

System Use

The system of referencing and cross-referencing represents one of the two essential pillars for consolidating the SUS because its structure makes the referral of patients to different hierarchical levels of healthcare viable.¹⁴ The greater the problem-solving capacity of a service, the more successful it will be in meeting the health needs of the population and also, when it is really necessary, in physically referring the patient to another service to continue the care.²⁸ An interesting alternative for optimizing the healthcare services offered to the population lies on the organization of primary healthcare with the incorporation of ICT at this level. Of the 263 teleconsultations analyzed in this study, 167 (63.5%) were solved in the UBS itself. This finding suggests that these 167 people did not need to be physically referred for specialized services, reducing the volume of labor-intensive face-to-face healthcare at this level of service. The teleconsultation system offered the patients assistance by specialists, improving the outcomes of service in primary care, preventing displacement of patients to the point-of-care by specialists, reducing the appointment waiting list, and providing a greater bond between patient and the UBS medical doctor. In addition, we can imply that there was a reduction in costs, both in terms of the reduced demand for specialized care and in the displacement and absenteeism of these patients. This represents a social gain, mainly for elderly users and those who have difficulty traveling. It can also help to strengthen ties between these users and the physicians who provide care, improving prospects in terms of continuity of care and adherence to the treatment.

The analysis of the teleconsultations stored in the system and reviewed by the physicians responsible for the care reveals that the guidelines and the observations proposed by the specialist stay recorded in the system. This return of information, relevant to the health of the user, comes from the answers to teleconsultations, which took place 96.6% of the time, and is very important for future consultations, as well as for the continuing provision of care. It is important to emphasize that the teleconsultation can make the physician more comfortable because there has already been a previous discussion with a specialist concerning the case in question, as demonstrated in a previous study.⁷

During the BH-Telehealth Program, the most requested specialties were dermatology, cardiology, endocrinology, and neurology.⁶ Data collected at the present study point partly in the same direction because both sets of data have arisen from the same social reality being researched but for a different period of time and at a different healthcare district. The most requested specialties were practically the same in both studies, but not in the same order.

Conclusions

The results of this research reveal that the general practitioners present in the UBS were those most frequently requesting teleconsultations, but it is important to encourage the participation of others to achieve more promising results. Teleconsultations were more common among adult women patients, and there was a predominance of offline teleconsultations. It was observed that cardiology and endocrinology were the most frequently requested specialties. The incorporation of telehealth resources in primary healthcare reduces the physical referral of patients to specialized services, representing large gains when offering healthcare services at a primary level. The structuring and systematization of teleconsultation also need to be reassessed, mainly in terms of specific place and time for the physician to do the teleconsultation. It is important to train and stimulate the physicians to use the system in order to get the most out of it. In an addition, the UBS manager and the municipal health secretary have to encourage the use and promote this type of healthcare.

Footnotes

Disclosure Statement

No competing financial interests exist.

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