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Teledermatology for primary care in remote areas in Brazil

Teledermatology for primary care
in remote areas in Brazil
Tati GP Assis
, Daniel MF Palhares
, Maria BM Alkmim
Milena S Marcolino
Accepted: 6 August 2013
The Telehealth Network of Minas Gerais (TNMG) is a
public telehealth service supporting primary care practi-
tioners in 660 of the 853 municipalities in the state of
Minas Gerais, in the southeast of Brazil. A wide range
of teleconsultations is provided. Store-and-forward tele-
dermatology began in 2007.
We conducted a retrospective study of the teleconsulta-
tions performed from the beginning of the service in April
2007 until August 2012. The teleconsultations were classi-
fied according to the professional who requested them and
the municipality from which they were submitted. The
number of municipalities covered by the TNMG increased
from 82 in 2007 to 660 in 2012. A sample of teleconsulta-
tions from January to May 2010 was individually assessed
to analyze the most frequent types of queries.
User satisfaction was assessed by the following
questions, which were available to users when they
received the response to their teleconsultation: (1) ‘‘Did
the teleconsultation avoid the patient’s referral?’’ (2) ‘‘Did
the teleconsultation answer your question?’’ (3) ‘‘What is
your level of satisfaction with the teleconsultation
During the study period, 43,429 teleconsultations were
performed. The most frequently requested specialty was
dermatology, 8724 (20%). Of these dermatology requests,
47% were requested outside normal working hours. In
2012, there were 275 teleconsultations in dermatology
per month. The majority of the questions were sent by
nurses (58%). The remainder were sent by physicians
(39%) or other healthcare professionals (3%).
There was an inverse relation between the number of
inhabitants in a municipality and the use of the service.
Municipalities with less than 5000 inhabitants were the
ones that sent the highest number of teleconsultations
(39% of the total). The ones with more than 100,000
inhabitants contributed only 0.4% of the total.
From January to May 2010, 413 teledermatology con-
sultations were performed. The majority were about
assistance for a particular patient (93%) and the remain-
der were educational questions (7%). The most frequent
type of query was about pharmacological treatment
(68%) or aetiology (60%), and the percentages were simi-
lar when comparing the teleconsultations requested by
physicians and the ones requested by nurses (Table 1).
The satisfaction survey on 2012 showed that 81% of
the teleconsultations had averted a referral. Most repon-
dents (97%) felt that the teleconsultation had answered
their question and 97% were satisfied with the network.
The success of teledermatology in the TNMG network is
probably related to many factors. First, it is relatively
simple to take pictures of skin problems and discuss the
case. Second, there is a high demand for referrals to
dermatologists, and teleconsultation is a rapid way of con-
tacting a specialist. Third, the high demand may be related
to the limited teaching of dermatology during under-
graduate medical courses, so that primary care physicians
lack specialist knowledge. The analysis of the types of
queries submitted showed a high prevalence of questions
about pharmacological treatment and aetiology. Other
frequent queries were about general medical advice, diag-
nosis and non-pharmacological treatment. Thus, the large
number of teleconsultations and the types of queries
reflect the potential of telemedicine to assist with simpler
cases in the local areas. The fact that 47% of telederma-
tology consultations were requested out of hours is an
indication of the importance of teledermatology for the
healthcare practitioners.
Nurses and physicians requested most of the telecon-
sultations. The unexpectedly large number from nurses,
who requested almost 20% more teleconsultations than
physicians, could be a result of the shortage of physicians
Telehealth Center, University Hospital, Universidade Federal de Minas
Gerais, Brazil
Medical School, Universidade Federal de Minas Gerais, Brazil
Corresponding author:
Tati Guerra Pezzini Assis, Telehealth Center, University Hospital, 110
Universidade Federal de Minas Gerais, Alfredo Balena Avenue 30130-100,
Belo Horizonte, Brazil.
Journal of Telemedicine and Telecare
19(8) 494–495
!The Author(s) 2013
Reprints and permissions:
DOI: 10.1177/1357633X13512059
in rural areas. It is important to note that many telecon-
sultations from nurses include questions concerning
pharmacological treatment. This represents a paradox,
since nurses are not allowed to prescribe according
Brazilian laws. The present study is the first to identify
this problem for healthcare policy makers.
It was common to have more than one query related to
the same clinical case, which illustrates the role of telecon-
sultation in providing a real case discussion, and avoiding
referral in about 80% of cases. This confirms the benefit of
teledermatology in preventing unnecessary referrals and,
consequently, reducing costs.
The remote and less developed municipalities usually
have a lower potential to attract healthcare practitioners
and limited structure to support primary care physicians.
In addition, healthcare practitioners in these municipali-
ties tend to be young and inexperienced, and are often
isolated and in need of further training.
Thus, these loca-
tions are the ones which benefit the most from the tele-
health service, as can be seen by their presence among the
sites that most request teleconsultations.
The present analysis has the limitation that there was
little information on patient follow-up after the first tele-
consultation. Thus, it was not possible to fully assess the
efficiency of the second opinion.
Telehealth appears to be a useful tool to provide specia-
lized care in dermatology to small and isolated cities.
Our study reports the successful experience of a public
telehealth service in Brazil, the TNMG. The lack of spe-
cialists in the small, remote and less developed municipa-
lities, in combination with the difficulty experienced by
primary care physicians in managing skin diseases,
explains the large numbers of requests for teleconsulta-
tions in dermatology. In addition, the study indicates
the need to improve the teaching of dermatology at under-
graduate level.
We thank the dermatologists Antoˆ nio Carlos Martins Guedes
and Alceu Luiz Camargo Villela Berbert, who performed the
1. Alkmin MB, Figueira RM, Marcolino MS, et al. Improving
patient access to specialized health care: the Telehealth
Network of Minas Gerais, Brazil. Bull World Health Organ
2. Andrade MV, Maia AC, Cardoso CS, Alkmim MB, Ribeiro
AL. Cost-benefit of the telecardiology service in the state of
Minas Gerais: Minas Telecardio Project. Arq Bras Cardiol
Table 1. The most frequent types of queries in the teleconsultations performed from January to May 2010*.
Total queries (%)
Physician queries (%)
Nurse queries (%)
Pharmacological treatment 68 73 63
Aetiology 60 58 62
General medical advice 17 16 18
Non-pharmacological treatment 14 13 15
Diagnosis 13 16 11
Surgical treatment 4 6 2
Patient follow-up 3 3 3
Prognosis 1 1 0.9
Assistance to pregnant women 0.7 1 0.5
Not specified 0.5 0 0.9
*subtotals add up to more than 100%, as the healthcare professional could ask more than one query in the same teleconsultation.
Assis et al. 495
... 59 High physician satisfaction rates of 97% have reinforced the utility of teledermatology in providing care to isolated cities and remote areas that have encountered acute dermatologist shortages. 60 In addition, a direct observational study revealed favorable patient views in the ability of teledermatology to limit expenses, decrease travel time, and facilitate shorter waiting periods. 61 According to Hsueh et al., perceptions of adequate care and follow-up and obtaining educational information were associated with a higher patient satisfaction rate of 78%. ...
... Assis et al. 60 A retrospective study was conducted in Minas Gerais, Brazil, to evaluate teleconsultations performed with the Telehealth Network of Minas Gerais (TNMG), which has been a service that has assisted primary care physicians. ...
... Al Quran et al. 60 A direct observational study that involved two rural hospitals in Jordan utilized patient questionnaires to determine patient satisfaction rates, among other types of information. ...
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Introduction: Dermatological access in rural regions has been impacted due to an acute, global dermatologist shortage coupled with a striking disparity in dermatologist density between urban and rural areas. As a result, the dermatological arena has been under notable pressure to amplify access. Teledermatology has entailed the use of technology to provide dermatological services to individuals located at a remote distance. The purpose of this literature review was to examine the effect of utilization of teledermatology to determine enhancement of dermatological access to residents of rural areas. Materials and Methods: This review followed a systematic approach and utilized five electronic databases to obtain peer-reviewed journal articles. A PRISMA approach was used and a total of 86 references were employed. Results: Teledermatology programs have been able to complement conventional dermatological care to enhance dermatological access to rural areas that have suffered from a shortage of dermatologists and could aid in supplementing traditional care as well. Within rural settings, the results of three studies in this review indicated the importance of improved quality for diagnostic precision, whereas one study reported that clinical images might not provide sufficient insight to deliver clear-cut diagnoses. In addition, enhancements in diagnostic precision could be obtained by upgrades in phone cameras to capture images. Finally, to most of the existing literature, in using teledermatology, physician satisfaction has been stronger than patient satisfaction. Conclusions: Teledermatology has had a beneficial impact in improving dermatological access to rural areas. The success of this technology is contingent upon the commitment and willingness of the dermatologist in utilizing it.
... Teledermatology is also applied in other areas where geographical distances are large and population density is low (4)(5)(6). An example is Australia, where a large teledermatology program is successfully running (4). ...
... An example is Australia, where a large teledermatology program is successfully running (4). Other examples are rural Brasil and Afghanistan (5,6). ...
... among international studies on skin tears. 3,4,16,18,26 The expansion of standardised tools like wound management solutions into international practice settings would help in comparing differences at the national level. ...
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Background Ageing populations are at risk of skin tears due to changes in their skin. Real-world data sets offer the ability to see current prevalence rates and practice changes to understand the size of the problem and glean practice insights. Aim Leveraging Swift Medical's big data set, a point-prevalence analysis was conducted over five years on skin tears in skilled nursing facilities (SNF) in North America, to better understand time to heal and explore the frequency of commonly used treatments and cleansing solutions for skin tears. Methods This descriptive prevalence study used a subset of an anonymised big dataset from participating SNFs across North America. Data from 188,675 skin tears in patients aged 20 years of age or older from 2017-2021 were included. Relative prevalence compared to other wounds was analysed, and healing times based on skin tear classification and frequency of primary, secondary and cleansing solutions were reported. Results More than 1.5 million wounds were included in this dataset, and skin tears accounted for 10.3-12.8% of skin tears in SNFs over the five-year period. The prevalence of skin tears increased with age. Median healing time ranged from 15-27 days, based on skin tear classification. Conclusion Big data sets can provide insight into current wound prevalence and practice patterns. The high prevalence of skin tears highlights the need for standard-ised tools to assess risk and prevent skin tears, and to educate clinicians on classifying and treating skin tears effectively.
... Brazil has the most developed TD practice in Latin America. Large-scale public TD programs have been developed in much of the country and some work with artificial intelligence (AI) incorporated [48,49]. ...
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Purpose of Review The use of teledermatology has been evolving slowly for the delivery of health care to remote and underserved populations. Improving technology and the recent COVID-19 pandemic have hastened its use internationally. Recent Findings Some barriers to the use of teledermatology have fallen considerably in the last year. Summary Teledermatology use has increased significantly in recent years in both government-sponsored and private health care systems and individual practices. There are no recognized international practice guidelines and variable use within countries. Many barriers remain to increasing the use of teledermatology.
... The small number of patients (8%) who are urgently evacuated or referred for specialized consultation or hospitalization at the Cayenne Hospital Center, suggests that the system has prevented a certain number of face to face consultation (92%) and therefore reduced costs related to these and associated transportation. A Brazilian study estimated at 81% the number of specialized consultations avoided thanks to telemedicine (5). In a literature review of 12 studies using teledermatology, the percentage of avoided travel was 43% (6). ...
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Introduction: French Guiana is an overseas region of France on the north coast of South America and is mostly covered by tropical rainforest. Most human settlements are located along the coast while some settlements are scattered across the hinterland. In 2001, the French public health service launched a telemedicine pilot project between the main hospital in Cayenne and remote health centers in French Guiana to tackle healthcare access inequalities. The aim of the present study was to review dermatology cases of the French Guiana telemedicine network to assess the use of telemedicine in dermatology, in order to evaluate its usefulness and propose ways to improve the system. Methods: A retrospective study was conducted on all dermatology cases referred between July 2015 and December 2016 through the French Guiana platform. The Model for Assessment of Telemedicine (MAST) methodology was used as recommended by the European Union. Results: A total of 254 cases were reviewed by dermatologists at Cayenne hospital over the 18-month study period, with a mean of 14 cases per month. All the 16 peripheral health centers used the telemedicine service during the study. In most cases (202/254, 80%), specialists provided a single diagnosis to the referrers. Infectious diseases represented the main reasons for requests (92/202, 46%) including 32% (29/92) of neglected tropical diseases like leprosy and cutaneous leishmaniasis. A total of 39% (100/258) peripheral centers answered the end-users' survey, and more than 85% found the answer delay was fast, the service useful and with an educational benefit. Overall, the accuracy of the diagnosis increased with the quality of the pictures provided, though the latter was good in only 60% (75/125) of the cases. Most patients for whom a teleconsultations has been required (234/254, 92%) have been managed in the peripheral health centers, while referring the patient to Cayenne was necessary for only 20/254 (8%). Conclusion: The telemedicine system in French Guiana appears to be an interesting solution to the lack of specialists and allowed a better access to specialized dermatology care for people living in the remote areas of this region.
... Advanced cameras with in-built dermoscopes are used, as well as regular cameras and mobile telephones (7). Teledermatology has particularly been successful and cost-effective in rural areas with large geographical distances and low population density, for example in Australia, Greenland, Brazil and Afghanistan (8)(9)(10). ...
Skin diseases are a big challenge in resource poor communities around the world; both in high-and low-income countries. In the past decades various control programmes have been set up in efforts to control, prevent and disrupt transmission leading to elimination of some of the infectious diseases. Mass drug administration/treatment (MDA) recommended by WHO, has been used for diseases including yaws, onchocerciasis, trachoma, lymphatic Filariasis and other skin NTDs in resource poor countries. Apart from MDA, telemedicine could be one of the tools that can be exploited to relieve the disease burden in limited resource countries. Improving access to primary healthcare may also assist in reducing the disease burden. Enhancing local knowledge of skin diseases and preventive and control measures through health education and community campaigns could provide the community with essential knowledge on how to manage skin diseases.
La dermatologie est une discipline fréquente en médecine générale. Les pathologies rencontrées sont très variées. Tous les médecins généralistes sont amenés à prendre en charge des pathologies dermatologiques régulièrement. La coopération médecin généraliste-dermatologue est essentielle dans la prise en charge prompte et efficace dans le cadre d'une demande de soins de plus en plus importante. Cependant, on retrouve dans plusieurs régions de France un nombre trop important de demandes par rapport au nombre de dermatologues exerçant dans ces territoires. Cette problématique de démographie médicale concerne un grand nombre de territoires (dont la Haute-Normandie). Selon la Direction de la recherche, des études, de l'évaluation et des statistiques (DREES), au ler janvier 2014, la densité moyenne était de 6,3 dermatologues pour 100 000 habitants. À cette problématique de couverture médicale déficitaire s'ajoute également la problématique d'âge, car selon une étude, la moyenne d'âge des dermatologues était de 52,4 ans. Soixante sept pour cent d'entre eux avaient plus de 50 ans et 25 avaient plus de 60 ans. De même, on observait une tendance à l'urbanisation de cette spécialité au niveau régional, car, parmi les dermatologues hauts-normands, 78,46 % exerçaient en ville. Les zones rurales pourraient être pénalisées dans l'accès aux soins dermatologiques. La télémédecine, actuellement en plein essor en France et dans plusieurs autres pays, est une des solutions proposées face à la problématique de cette démographie médicale déficitaire. Dans le cadre d'une expérimentation faisant l'objet d'un appel à projets par l'ARS de Haute-Normandie, cette thèse propose l'étude des méthodes d'implémentation, jusqu'au moment de l'inclusion des premiers patients. L'étude, qui prévoit pour centres de téléexpertise, les MSP de Neuchâtel en BRAY, Saint Romain de COLBOSC et de Gaillon, analyse principalement les difficultés rencontrés par le groupe de travail lors des réunions entre novembre 2013 et avril 2016. Elle se propose également de servir comme support pour les autres régions qui souhaiteraient implémenter ce type d'expérimentation, jusqu'à ce jour souvent ignoré mais désormais incontournable.
En deux décennies, la télédermatologie est devenue une des applications les plus développées de la télémédecine. Le système de soins français est marqué par une démographie médicale en décroissance, avec une baisse de 30% des dermatologues prévue en 2030. Parallèlement, la demande de soins augmente dans une population sans cesse croissante et vieillissante. La télédermatologie est actuellement à une étape charnière de son développement en France. Son déploiement, encore limité, nécessite des évaluations médico-économiques de grande ampleur. Pour cela, il est nécessaire de définir des objectifs « précis et mesurables », afin d’en évaluer son réel impact. Cependant, aucune étude n’a, actuellement, répertorié et évalué les indicateurs en télédermatologie. Objectif : Identifier de manière exhaustive les indicateurs permettant d’évaluer les procédures de télédermatologie et évaluer leur pertinence et leurs résultats. Méthodes : Revue systématique de la littérature conduite sur PubMed jusqu’en septembre 2017, à partir d’une requête comportant les mots-clés suivants : « telemedicine », « dermatology », « quality improvement ». Résultats : La recherche a abouti à 372 articles, dont 125 ont été retenus. Quatorze indicateurs ont été identifiés et répartis en quatre catégories. La fiabilité diagnostique était l’indicateur le plus souvent évalué (49 études) contre seulement 17 études économiques. Les résultats de certains indicateurs étaient difficiles à comparer et donc à généraliser du fait de l’absence de mesure validée, notamment pour la satisfaction. Conclusion : La télédermatologie est un outil prometteur qui offre de nombreux avantages sanitaires. À l'avenir, d’autres recherches sont nécessaires pour évaluer son impact à la fois économique et sur l’état de santé du patient; basées sur des moyens de mesure spécifiques et standardisés.
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The Brazilian population lacks equitable access to specialized health care and diagnostic tests, especially in remote municipalities, where health professionals often feel isolated and staff turnover is high. Telehealth has the potential to improve patients' access to specialized health care, but little is known about it in terms of cost-effectiveness, access to services or user satisfaction. In 2005, the State Government of Minas Gerais, Brazil, funded the establishment of the Telehealth Network, intended to connect university hospitals with the state's remote municipal health departments; support professionals in providing tele-assistance; and perform tele-electrocardiography and teleconsultations. The network uses low-cost equipment and has employed various strategies to overcome the barriers to telehealth use. The Telehealth Network connects specialists in state university hospitals with primary health-care professionals in 608 municipalities of the large state of Minas Gerais, many of them in remote areas. From June 2006 to October 2011, 782,773 electrocardiograms and 30 883 teleconsultations were performed through the network, and 6000 health professionals were trained in its use. Most of these professionals (97%) were satisfied with the system, which was cost-effective, economically viable and averted 81% of potential case referrals to distant centres. To succeed, a telehealth service must be part of a collaborative network, meet the real needs of local health professionals, use simple technology and have at least some face-to-face components. If applied to health problems for which care is in high demand, this type of service can be economically viable and can help to improve patient access to specialized health care.
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Telecardiology is a tool that can aid in cardiovascular care, mainly in towns located in remote areas. However, economic assessments on this subject are scarce and have yielded controversial results. To evaluate the cost-benefit of implementing a Telecardiology service in remote, small towns in the state of Minas Gerais, Brazil. The study used the database from the Minas Telecardio (MTC) Project, developed from June 2006 to November 2008, in 82 towns in the countryside of the state. Each municipality received a microcomputer with a digital electrocardiograph, with the possibility of transmitting ECG tracings and communicating with the on-duty cardiologist at the University hospital. The cost-benefit analysis was carried out by comparing the cost of performing an ECG in the project versus the cost of performing it by patient referral to another city. The average cost of an ECG in the MTC project was R$ 28.92, decomposed into R$ 8.08 for the cost of implementation and R$ 20.84 for maintenance. The cost simulation of the ECG with referral ranged from R$ 30.91 to R$ 54.58, with the cost-benefit ratio being always favorable to the MTC program, regardless of the type of calculation used for referral distance. The simulations considered the financial sponsor's and society's points-of-view. The sensitivity analysis with variation of calibration parameters confirmed these results. The implementation of a Telecardiology system as support to primary care in small Brazilian towns is feasible and economically beneficial, and can be used as a regular program within the Brazilian public health system.