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Teledermatology for primary care in remote areas in Brazil

Authors:
TAILPIECE/Correspondence
Teledermatology for primary care
in remote areas in Brazil
Tati GP Assis
1,2
, Daniel MF Palhares
1,2
, Maria BM Alkmim
1
and
Milena S Marcolino
1,2
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.
1
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
system?’’
1
Results
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.
Discussion
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
1
Telehealth Center, University Hospital, Universidade Federal de Minas
Gerais, Brazil
2
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.
Email: tatigpassis@gmail.com
Journal of Telemedicine and Telecare
19(8) 494–495
!The Author(s) 2013
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DOI: 10.1177/1357633X13512059
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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.
2
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.
1
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.
Conclusion
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.
Acknowledgements
We thank the dermatologists Antoˆ nio Carlos Martins Guedes
and Alceu Luiz Camargo Villela Berbert, who performed the
teleconsultations.
References
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
2012;90:373–378.
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
2011;97(4):307–16.
Table 1. The most frequent types of queries in the teleconsultations performed from January to May 2010*.
Total queries (%)
n¼413
Physician queries (%)
n¼189
Nurse queries (%)
n¼219
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
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... 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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