COVID-19 Telehealth Service Can Increase Access to the Health Care System and Become a Cost-Saving Strategy.

Introduction: Data addressing the economic aspects of telehealth initiatives are incipient. This study aimed to evaluate the labor costs for running a COVID-19 telehealth system and its potential incremental access to health care service. Methods: From July 2020 to July 2021, data from a Brazilian teleconsultation service were analyzed. Labor costs were estimated by time-driven activity-based costing. A Generalized Reduced Gradient solving method was coded to maximize the mean incremental access rate and two scenarios were considered to compare the teleconsultation with the in-person consultation: (1) only the length of time that patients spent with a clinician in an in-person consultation was accounted and (2) in addition to the medical consultation, nursing screening was accounted. The mean incremental access rate of the teleconsultation service was defined as a maximization objective in the model. Results: Mean labor costs per medical and nursing teleconsultations are Int$ 24 and Int$ 10, based on data analyses from 25,258 patients. Telemonitoring a patient with a daily call for 7 days costs, on average, Int$ 14. COVID-19 teleconsultation service represents, on average, an incremental access to medical consultation rate of 35% to 52% (min 23% max 63%) for the scenarios (1) and (2), respectively, and considering the current consumed budget for this service. Discussion: A COVID-19 telehealth service contributes to increasing access to the health care system without increasing costs. These services can be included in the bundle of care strategies offered in a national public health care system that looks for more sustainable strategies to provide care.

Synchronous Teleconsultation and Monitoring Service Targeting COVID-19: Leveraging Insights for Postpandemic Health Care.

BACKGROUND: Although a great number of teleconsultation services have been developed during the COVID-19 pandemic, studies assessing usability and health care provider satisfaction are still incipient. OBJECTIVE: This study aimed to describe the development, implementation, and expansion of a synchronous teleconsultation service targeting patients with symptoms of COVID-19 in Brazil, as well as to assess its usability and health care professionals' satisfaction. METHODS: This mixed methods study was developed in 5 phases: (1) the identification of components, technical and functional requirements, and system architecture; (2) system and user interface development and validation; (3) pilot-testing in the city of Divinópolis; (4) expansion in the cities of Divinópolis, Teófilo Otoni, and Belo Horizonte for Universidade Federal de Minas Gerais faculty and students; and (5) usability and satisfaction assessment, using Likert-scale and open-ended questions. RESULTS: During pilot development, problems contacting users were solved by introducing standardized SMS text messages, which were sent to users to obtain their feedback and keep track of them. Until April 2022, the expanded system served 31,966 patients in 146,158 teleconsultations. Teleconsultations were initiated through chatbot in 27.7% (40,486/146,158) of cases. Teleconsultation efficiency per city was 93.7% (13,317/14,212) in Teófilo Otoni, 92.4% (11,747/12,713) in Divinópolis, and 98.8% (4981/5041) in Belo Horizonte (university campus), thus avoiding in-person assistance for a great majority of patients. In total, 50 (83%) out of 60 health care professionals assessed the system's usability as satisfactory, despite a few system instability problems. CONCLUSIONS: The system provided updated information about COVID-19 and enabled remote care for thousands of patients, which evidenced the critical role of telemedicine in expanding emergency services capacity during the pandemic. The dynamic nature of the current pandemic required fast planning, implementation, development, and updates in the system. Usability and satisfaction assessment was key to identifying areas for improvement. The experience reported here is expected to inform telemedicine strategies to be implemented in a postpandemic scenario.

Development and Evaluation of a Mobile Decision Support System for Hypertension Management in the Primary Care Setting in Brazil: Mixed-Methods Field Study on Usability, Feasibility, and Utility.

BACKGROUND: Despite being an important cardiovascular risk factor, hypertension has low control levels worldwide. Computerized clinical decision support systems (CDSSs) might be effective in reducing blood pressure with a potential impact in reducing cardiovascular risk. OBJECTIVE: The goal of the research was to evaluate the feasibility, usability, and utility of a CDSS, TeleHAS (tele-hipertensão arterial sistêmica, or arterial hypertension system), in the care of patients with hypertension in the context of a primary care setting in a middle-income country. METHODS: The TeleHAS app consists of a platform integrating clinical and laboratory data on a particular patient, from which it performs cardiovascular risk calculation and provides evidence-based recommendations derived from Brazilian and international guidelines for the management of hypertension and cardiovascular risk. Ten family physicians from different primary care units in the city of Montes Claros, Brazil, were randomly selected to use the CDSS for the care of hypertensive patients for 6 months. After 3 and 6 months, the feasibility, usability, and utility of the CDSS in the routine care of the health team was evaluated through a standardized questionnaire and semistructured interviews. RESULTS: Throughout the study, clinicians registered 535 patients with hypertension, at an average of 1.24 consultations per patient. Women accounted for 80% (8/10) of participant doctors, median age was 31.5 years (interquartile range 27 to 59 years). As for feasibility, 100% of medical users claimed it was possible to use the app in the primary care setting, and for 80% (8/10) of them it was easy to incorporate its use into the daily routine and home visits. Nevertheless, 70% (7/10) of physicians claimed that the time taken to fill out the CDSS causes significant delays in service. Clinicians evaluated TeleHAS as good (8/10, 80% of users), with easy completion and friendly interface (10/10, 100%) and the potential to improve patients' treatment (10/10, 100%). A total of 90% (9/10) of physicians had access to new knowledge about cardiovascular risk and hypertension through the app recommendations and found it useful to promote prevention and optimize treatment. CONCLUSIONS: In this study, a CDSS developed to assist the management of patients with hypertension was feasible in the context of a primary health care setting in a middle-income country, with good user satisfaction and the potential to improve adherence to evidence-based practices.

The Impact of mHealth Interventions: Systematic Review of Systematic Reviews.

BACKGROUND: Mobile phone usage has been rapidly increasing worldwide. mHealth could efficiently deliver high-quality health care, but the evidence supporting its current effectiveness is still mixed. OBJECTIVE: We performed a systematic review of systematic reviews to assess the impact or effectiveness of mobile health (mHealth) interventions in different health conditions and in the processes of health care service delivery. METHODS: We used a common search strategy of five major scientific databases, restricting the search by publication date, language, and parameters in methodology and content. Methodological quality was evaluated using the Measurement Tool to Assess Systematic Reviews (AMSTAR) checklist. RESULTS: The searches resulted in a total of 10,689 articles. Of these, 23 systematic reviews (371 studies; more than 79,665 patients) were included. Seventeen reviews included studies performed in low- and middle-income countries. The studies used diverse mHealth interventions, most frequently text messaging (short message service, SMS) applied to different purposes (reminder, alert, education, motivation, prevention). Ten reviews were rated as low quality (AMSTAR score 0-4), seven were rated as moderate quality (AMSTAR score 5-8), and six were categorized as high quality (AMSTAR score 9-11). A beneficial impact of mHealth was observed in chronic disease management, showing improvement in symptoms and peak flow variability in asthma patients, reducing hospitalizations and improving forced expiratory volume in 1 second; improving chronic pulmonary diseases symptoms; improving heart failure symptoms, reducing deaths and hospitalization; improving glycemic control in diabetes patients; improving blood pressure in hypertensive patients; and reducing weight in overweight and obese patients. Studies also showed a positive impact of SMS reminders in improving attendance rates, with a similar impact to phone call reminders at reduced cost, and improved adherence to tuberculosis and human immunodeficiency virus therapy in some scenarios, with evidence of decrease of viral load. CONCLUSIONS: Although mHealth is growing in popularity, the evidence for efficacy is still limited. In general, the methodological quality of the studies included in the systematic reviews is low. For some fields, its impact is not evident, the results are mixed, or no long-term studies exist. Exceptions include the moderate quality evidence of improvement in asthma patients, attendance rates, and increased smoking abstinence rates. Most studies were performed in high-income countries, implying that mHealth is still at an early stage of development in low-income countries.

A telessaúde como ferramenta de apoio à Atenção Primária em Saúde: a experiência da Rede de Teleassistência de Minas Gerais / The telehealth as a support tool for primary health care: the experience of Telehealth Network of Minas Gerais

O objetivo deste artigo é relatar a experiência exitosa da Rede de Teleassistência de Minas Gerais (RTMG), um serviço público de telessaúde em larga escala. A RTMG foi constituída pela parceria entre seis universidades públicas do estado de Minas Gerais (MG). Recursos públicos e de agências de pesquisa financiaram suas atividades. A telecardiologia foi o foco inicial da Rede com realização de eletrocardiograma (ECG) e plantões de cardiologia, posteriormente, um sistema de teleconsultoria em especialidades foi incorporado. A RTMG atualmente abrange 780 municípios com 1.000 pontos de telessaúde em MG. De junho de 2006 a março de 2016, 2,538,592 ECGs e 75,866 teleconsultorias foram realizados e mais de 8.000 profissionais foram treinados. As atividades da RTMG possibilitam o acesso de pacientes de municípios remotos ao cuidado especializado, qualifica os encaminhamentos e contribui para a melhoria do cuidado. Atualmente, os serviços de telessaúde foram integrados ao sistema de saúde em MG. (AU)

The purpose of this article is to report the successful experience of The Telehealth Network of Minas Gerais (TNMG), a public service of telehealth on a large scale. The TNMG was formed through a partnership among six public universities at the Minas Gerais (MG) state. Public funding and research agencies support their activities. The telecardiology was the initial focus providing tele-electrocardiography, later teleconsulting in specialties was incorporated. The TNMG currently covers 780 municipalities in MG with 1,000 points in telehealth. From June 2006 to March 2016, a total of 2,538,592 and 75.866 teleconsultation were done and more than 8,000 professionals were trained. The activities of TNMG allow access of patients from remote municipalities to specialized healthcare, qualify referrals and contribute to the improvement of care. Currently, telehealth services were integrated into to the health system in MG. (AU)

Teleconsultorias de fonoaudiologia em um serviço público de telessaúde de larga escala / Speech, language and hearing sciences teleconsultations in a large public telehealth service

RESUMO Objetivo: analisar o perfil das teleconsultorias de fonoaudiologia realizadas em serviço público de telessaúde de larga escala em Minas Gerais. Método: foram analisadas todas as teleconsultorias consecutivas de fonoaudiologia realizadas de fevereiro de 2011 a maio de 2014. As teleconsultorias foram agrupadas de acordo com tipo de dúvida, profissional solicitante e área de atuação fonoaudiológica. Resultados: as 259 teleconsultorias realizadas no período do estudo foram originadas de 81 municípios. A maior demanda de teleconsultorias foi dos próprios fonoaudiólogos (64,5%), seguidos de enfermeiros (27,0%) e médicos (5,0%). A maior parte das dúvidas eram assistenciais (81%), sendo que, destas, 35% eram para auxílio na definição diagnóstica e 65% para discussão de procedimentos e sugestão de condutas terapêuticas. Esta proporção foi semelhante, independente da formação do profissional solicitante: fonoaudiólogo e não fonoaudiólogo (65,7% vs. 64,9%, p=1,00). A maioria das dúvidas estava relacionada à área da linguagem (47%) e à motricidade oral (29%), seguidas de voz (20%), audiologia (18%), disfagia (10%) e saúde pública (3%). Conclusão: neste estudo, foi observado que a maioria das dúvidas para o serviço de teleconsultorias em fonoaudiologia estavam relacionadas à área da linguagem, mas há demanda em todas as áreas de abrangência da profissão. Embora o uso da teleconsultoria em fonoaudiologia seja ainda incipiente, observa-se grande potencial de utilização deste instrumento na prática clínica.

ABSTRACT Purpose: to analyze the profile of Speech, Language and Hearing Sciences teleconsultations of a large scale public telehealth service in Minas Gerais, Brazil. Methods: all Speech-Language Pathology teleconsultations performed from February 2011 to May 2014 were assessed and classified according to the type of questions, professional who sent the solicitation and the speech-language pathologist area of expertise. Results: the 259 teleconsultations performed during the study period were originated from 81 cities. The majority of the solicitations were originated from speech-language pathologists (64.5%), followed by nurses (27.0%) and physicians (5.0%), and were related to patients' assistance (81%). Among these, 35% were about diagnosis and 65% about discussion of procedures and therapeutic approaches. There was no difference with regards to the type of solicitation and healthcare practitioner, whether speech-language pathologist or not (65.7% vs. 64.9%, p=1.00). The majority of the questions were about language (47%), followed by oral motor functions (29%), voice (20%), audiology (18%), dysphagia (10%) and public health (3%). Conclusion: in this study, the majority of the solicitations to a Speech, Language and Hearing Sciences teleconsultation service were about language, although there was demand for all fields. Although the use of teleconsultations in Speech-Language Pathology, is still in its early stages there is great potential for using this tool in clinical practice.

The Impact of a Clinical Decision Support System in Diabetes Primary Care Patients in a Developing Country.

BACKGROUND: Telehealth strategies have the potential to improve diabetes care, but there is a lack of evidence about the impact of these strategies in developing countries. Our objective was to analyze the feasibility, usability, and clinical impact of a decision support system (DSS) in Brazilian primary care diabetes patients. MATERIALS AND METHODS: This was a quasi-experimental study that included type 2 diabetes primary care patients >40 years of age. Patients were assessed before (during 6 months) and after the implementation of the DSS application (4 months). The DSS application, used by health professionals, included clinical evaluations and blood glucose measurements and generated specific recommendations based on the data entered. RESULTS: In total, 145 patients were included (mean age, 62.0 ± 9.9 years), 62.1% were female, and 70.0% had been diagnosed with diabetes more than 5 years ago. Overall, there was no decrease in median hemoglobin A1c (HbA1c), from 7.7% (range, 6.5-9.8%) to 7.4% (range, 6.5-9.2%) (P for slope = 0.347). Subgroup analysis showed that patients with an HbA1c level of ≥9% at baseline had a significant reduction in median HbA1c level, from 10.5% (range, 9.9-11.3%) to 10.0% (range, 8.9-10.9%) (P for difference of slope between subgroups = 0.004). The reduction occurred in the first phase of the study, before the DSS use. Healthcare practitioners considered the DSS easy to use (99%) and believed that it provided useful information for patient care (100%). CONCLUSIONS: In this study the improvement of glycemic control before the application in more decompensated patients (HbA1c ≥9%) probably reflects the systematization of diabetes care. The DSS use did not improve the HbA1c level, possibly because of the short follow-up and/or infrequent use by the healthcare practitioners.

Teleconsultations to Provide Support for Primary Care Practitioners and Improve Quality of care--the Experience of a Large Scale Telehealth Service in Brazil.

This observational restrospective study was designed to assess teleconsultations performed by a public telehealth service in Brazil. A satisfaction survey was used to assess the impact on clinical practice. A total of 63,975 teleconsultations were performed, from April 2007 to November 2014. Family physicians (33%) and dermatologists (19%) answered most queries. From January to February 2014 (n=895), the most frequent queries were about etiology (30%) and pharmacological treatment (25%). The satisfaction survey in 2014 (n=571) showed that teleconsultations avoided patient referal in 78%. This study aims to shows the potential of telehealth to provide support to primary care practitioners in remote cities.

2,000,000 Electrocardiograms by Distance: An Outstanding Achievement for Telehealth in Brazil.

Our aim is to describe the evolution of the telediagnostic service of the Telehealth Network of Minas Gerais (TNMG), a public telehealth service in Brazil. It started in 2006 with 82 cities, restricted to electrocardiography analysis. Currently it extends to 772 cities--performing also Holter, ambulatory blood pressure monitoring and retinography analysis--and 48 ambulances in the north of the state, as part of a myocardial infarction system of care. Using low-cost equipment and simple technology, TNMG has employed various strategies to increase telehealth use. The number of ECGs performed by TNMG has progressively increased. It was expected to achieve 2 million in February 2015. The utilization rates were around 90%. It proved to be economically sound, promoting savings of 45M USD for an investment of 10.2M USD. It is currently a regular health service in the state, integrated into the healthcare system. In conclusion, the telehealth model developed in Minas Gerais produced good clinical and economical results.

Prevalence of normal electrocardiograms in primary care patients.

OBJECTIVE: Knowing the proportion the proportion of normal and abnormal electrocardiograms (ECGs) in primary care patients allows us to estimate the proportion of exams that can be analyzed by the general practitioner with minimal training in ECG interpretation, in addition to being epidemiologically relevant. The objective of this study is to assess the prevalence of normal ECGs in primary care patients. METHODS: All digital ECGs analyzed by the cardiologists of Telehealth Network of Minas Gerais (TNMG) in 2011 were evaluated. TNMG is a public telehealth service that provides support to primary care professionals in 662 municipalities in the state of Minas Gerais, Brazil. RESULTS: During the study period, 290,795 ECGs were analyzed (mean age 51 ± 19 years), 57.6% were normal. This proportion was higher in women (60.1 vs 57.6%, p <0.001) and lower in patients with hypertension (45.8% vs 63.2%, p <0.001) or diabetes (43.3% vs 63.2%, p <0.001). A progressive reduction in the prevalence of normal ECG with increasing age was observed. Among the ECGs of patients under investigation for chest pain, 58.7% showed no abnormalities. CONCLUSION: The prevalence of normal ECGs in primary care patients is higher than 50% and this proportion decreases with age and comorbidities. Most ECGs performed for investigation of chest pain in primary care shows no abnormality.

Prevalence of normal electrocardiograms in primary care patients / Prevalência de eletrocardiogramas normais em pacientes da atenção primária

Objective: Knowing the proportion the proportion of normal and abnormal electrocardiograms (ECGs) in primary care patients allows us to estimate the proportion of exams that can be analyzed by the general practitioner with minimal training in ECG interpretation, in addition to being epidemiologically relevant. The objective of this study is to assess the prevalence of normal ECGs in primary care patients. Methods: all digital ECGs analyzed by the cardiologists of Telehealth Network of Minas Gerais (TNMG) in 2011 were evaluated. TNMG is a public telehealth service that provides support to primary care professionals in 662 municipalities in the state of Minas Gerais, Brazil. Results: during the study period, 290,795 ECGs were analyzed (mean age 51 ± 19 years), 57.6% were normal. This proportion was higher in women (60.1 vs 57.6%, p <0.001) and lower in patients with hypertension (45.8% vs 63.2%, p <0.001) or diabetes (43.3% vs 63.2%, p <0.001). A progressive reduction in the prevalence of normal ECG with increasing age was observed. Among the ECGs of patients under investigation for chest pain, 58.7% showed no abnormalities. Conclusion: the prevalence of normal ECGs in primary care patients is higher than 50% and this proportion decreases with age and comorbidities. Most ECGs performed for investigation of chest pain in primary care shows no abnormality. .

Objetivo: o conhecimento da proporção de eletrocardiogramas (ECG) normais e alterados em pacientes atendidos na atenção primária permite estimar a proporção de exames que pode ser analisada pelo médico generalista com formação mínima na interpretação do ECG, além de ter relevância epidemiológica. O objetivo deste estudo é avaliar a prevalência de ECG sem alterações em pacientes atendidos na Atenção Primária. Métodos: todos os ECG digitais analisados pelos cardiologistas da Rede de Teleassistência de Minas Gerais (RTMG) no ano de 2011 foram avaliados. A RTMG é um serviço público de telessaúde, que atende a atenção primária em 662 municípios em Minas Gerais, Brasil. Resultados: no período do estudo, 290.795 ECG foram analisados (idade média 51±19 anos) e 57,6% deles eram normais. Essa proporção foi maior em mulheres (60,1 vs. 57,6%, p < 0,001) e menor em pacientes com hipertensão (45,8% vs. 63,2%, p < 0,001) ou diabetes (43,3% vs. 63,2%, p < 0,001). Foi observada redução progressiva na prevalência de ECG normal com o aumento da idade. Entre os ECG de pacientes em investigação para dor torácica, 58,7% não apresentaram alterações. Conclusão: a prevalência de ECG normais em pacientes da atenção primária é superior a 50% e essa proporção diminui com a idade e a presença de comorbidades. A maioria dos ECG realizados para investigação de dor torácica na atenção primária não tem alterações. .

Telemedicine application in the care of diabetes patients: systematic review and meta-analysis.

BACKGROUND: The impact of telemedicine application on the management of diabetes patients is unclear, as the results are not consistent among different studies. The objective of this study is to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing the impact of telemedicine interventions on change in hemoglobin A1c (HbA1c), blood pressure, LDL cholesterol (LDL-c) and body mass index (BMI) in diabetes patients. METHODS: Electronic databases MEDLINE, Cochrane Central Register of Controlled Trials and LILACS were searched to identify relevant studies published until April 2012, supplemented by references from the selected articles. Study search and selection were performed by independent reviewers. Of the 6.258 articles retrieved, 13 RCTs (4207 patients) were included. Random effects model was applied to estimate the pooled results. RESULTS: Telemedicine was associated with a statistically significant and clinically relevant absolute decline in HbA1c level compared to control (mean difference -0.44% [-4.8 mmol/mol] and 95% confidence interval [CI] -0.61 to -0.26% [-6.7 to -2.8 mmol/mol]; p<0.001). LDL-c was reduced in 6.6 mg/dL (95% CI -8.3 to -4.9; p<0.001), but the clinical relevance of this effect can be questioned. No effects of telemedicine strategies were seen on systolic (-1.6 mmHg and 95% CI -7.2 to 4.1) and diastolic blood pressure (-1.1 mmHg and 95% CI -3.0 to 0.8). The 2 studies that assessed the effect on BMI demonstrated a tendency of BMI reduction in favor of telemedicine. CONCLUSIONS: Telemedicine strategies combined to the usual care were associated with improved glycemic control in diabetic patients. No clinical relevant impact was observed on LDL-c and blood pressure, and there was a tendency of BMI reduction in diabetes patients who used telemedicine, but these outcomes should be further explored in future trials.