Direct Impact on Costs of the Teledermatology-Centered Patient Triage in the State of Santa Catarina - Analysis of the 2014-2018 Data

Abstract

This study is based upon statistics from 83,100 teledermatological examination protocols that were performed at Primary Healthcare Facilities in the context of the STT/SC between January, 2014 and June, 2018 and employed for patient triage. The amount of dermatologic patients with low complexity in reference center brought the need to implement a screening system able to reduce the number of referrals and increase resolution at UBS, was deployed teledermatology. There were no Brazilian studies assessing the economy of this system. Objectives: To analyze the financial impact of the implementation of teledermatology in screening UBS patients. Methods: Cross-sectional observational epidemiological study with teledermatology patients of the state of Santa Catarina.

Full text

Technical Report
INCoD/TELEMED.04.2018.E.01
Direct Impact on Costs of the
Teledermatology-
Centered Patient Triage
in the State of Santa Catarina
Analysis of the 2014-2018 Data
Aldo von Wangenheim
Daniel Holthausen Nunes
JUNE – 2018

Instituto Nacional para Convergência Digital
Universidade Federal de Santa Catarina - UFSC - Campus Universitário João David Ferreira Lima
Departamento de Informática e Estatística - Sala 320 - Trindade - Florianópolis/SC - CEP 88040-970
Fone / FAX: +55 48 3721-9516 R.17
www.incod.ufsc.br

Direct Impact on Costs of the
Teledermatology-Centered Patient Triage
in the State of Santa Catarina
Analysis of the 2014-2018 Data
Authors:
Aldo von Wangenheim
Daniel Holthausen Nunes
Júlia de Melo Koneski
Version 1.0
Status: Final
Distribution: Public
JUNE - 2018

© 2018-2017 INCoD – Instituto Nacional para Convergência Digital
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Nenhuma parte deste documento, sem autorização prévia por escrito do Instituto, poderá ser
reproduzida ou transmitida sejam quais forem os meio empregados: eletrônicos, mecânicos,
fotográficos, gravação ou quaisquer outros.
INCoD – Instituto Nacional para Convergência Digital
Universidade Federal de Santa Catarina - UFSC
Campus Universitário João David Ferreira Lima - Trindade
Departamento de Informática e Estatística - Sala 320
Florianópolis-SC - CEP 88040-970
Fone / FAX: +55 48 3721-9516 R.17
www.incod.ufsc.br
ISSN 2236-5281

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Abstract
Introduction: This study is based upon statistics from 83,100 teledermatological examination protocols that
were performed at Primary Healthcare Facilities in the context of the STT/SC between January, 2014 and
June, 2018 and employed for patient triage. The amount of dermatologic patients with low complexity in
reference center brought the need to implement a screening system able to reduce the number of referrals
and increase resolution at UBS, was deployed teledermatology. There were no Brazilian studies assessing
the economy of this system. Objectives: To analyze the financial impact of the implementation of
teledermatology in screening UBS patients. Methods: Cross-sectional observational epidemiological study
with teledermatology patients of the state of Santa Catarina.

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in the State of Santa Catarina
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Table of Contents
Abstract ................................................................................................................................................... 5
1 Introduction ...................................................................................................................................... 9
1.1 Short History of Teledermatology in Santa Catarina ............................................................... 9
1.2 Patient Flow in Teledermatology .......................................................................................... 11
2 System Efficiency and Travel Costs Avoidance .............................................................................. 14
3 Method .......................................................................................................................................... 15
3.1 Studied Population ................................................................................................................ 15
3.2 Exclusion Criteria ................................................................................................................... 15
3.3 Biases ..................................................................................................................................... 15
3.4 Variables ................................................................................................................................ 16
3.5 Data Collection ...................................................................................................................... 17
3.5.1 Procedures ..................................................................................................................... 17
3.5.2 Data Collection Instrument: GISTelemed ...................................................................... 17
3.5.3 Data Sources for Cost Variables .................................................................................... 20
3.6 Travel Distance Estimation .................................................................................................... 20
3.7 Data Sources and Coverage ................................................................................................... 22
3.8 Ethic Aspects .......................................................................................................................... 29
4 Results ............................................................................................................................................ 30
4.1 Overview ................................................................................................................................ 30
4.2 2014 ....................................................................................................................................... 35
4.2.1 Spatial Distribution: Healthcare Macro-Regions ........................................................... 36
4.2.2 Spatial Distribution: Municipalities ............................................................................... 36
4.2.3 Maximum Estimated Economy ...................................................................................... 37
4.2.4. Minimum Estimated Economy ...................................................................................... 38
4.3 2015 ....................................................................................................................................... 39
4.3.1 Spatial Distribution: Healthcare Macro-Regions ........................................................... 40
4.3.2 Spatial Distribution: Municipalities ............................................................................... 40
4.3.3 Maximum Estimated Economy ...................................................................................... 41
4.3.4. Minimum Estimated Economy ...................................................................................... 42
4.4 2016 ....................................................................................................................................... 43
4.4.1 Spatial Distribution: Healthcare Macro-Regions ........................................................... 44
4.4.2 Spatial Distribution: Municipalities ............................................................................... 44
4.4.3 Maximum Estimated Economy ...................................................................................... 45
4.4.4. Minimum Estimated Economy ...................................................................................... 46
4.5 2017 ....................................................................................................................................... 47
4.5.1 Spatial Distribution: Healthcare Macro-Regions ........................................................... 48

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4.5.2 Spatial Distribution: Municipalities ............................................................................... 48
4.5.3 Maximum Estimated Economy ...................................................................................... 49
4.5.4. Minimum Estimated Economy ...................................................................................... 50
4.6 Jan.-June 2018 ....................................................................................................................... 51
4.6.1 Spatial Distribution: Healthcare Macro-Regions ........................................................... 52
4.6.2 Spatial Distribution: Municipalities ............................................................................... 52
4.6.3 Maximum Estimated Economy ...................................................................................... 53
4.6.4. Minimum Estimated Economy ...................................................................................... 54
4.7 Consolidated Cost Reduction Estimates ................................................................................ 55
4.8 Impact on Resolubility and Referrals ..................................................................................... 57
4.8.1 Impact on Referrals ....................................................................................................... 57
4.8.2 Impact on Resolubility ................................................................................................... 59
5 Discussion ...................................................................................................................................... 61
5.1. Threats to Validity ................................................................................................................. 62
6 References ..................................................................................................................................... 63

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1 Introduction
Teledermatology is the field of telemedicine that is aimed at the study of the Information and
Communication Technologies directed to Dermatology in order to allow dermatologic care without
the physical presence of a specialist. It allows healthcare management and planning, research, clinical
second opinion on cases and dermatological assistance to populations where access to a specialist is
difficult or unavailable. Besides, it allows the sending of dermatological medical information between
two or more physically or geographycally separated points, with the purpose of providing healthcare
and patient education, benefitting also all professionals involved in the process [1][2].
In Brazil telemedicine is regulated and supervised by the Brazilian Federal Medicine Council (CFM), that
defines telemedicine as the practice of medicine through the usage of interactive and audio-visual
technologies and digital data interchange, supported by an adequate infra-structure, accordingly to norms
establisehd by the CFM [3].
Telemedicine is inserted in the Brazilian national scenario in the form of specialities. Teldermatology profits
specially from telemedicine technologies and infrastructure because skin examinations are visual by nature.
It can be an important tool in the diagnostic and treatment of dermatological pathologies, particularly in
areas where specialized services are not available [4].
1.1 Short History of Teledermatology in Santa Catarina
In the State of Santa Catarina, the telemedicine service was implemented in 2005 with the objective to
offer citizens a better access to medical examinations through the development of a technological
infrastructure that supports the performing of medical examinations at an upstate location and the
subsequent sending of these examinations to a central server and the issuing of reports by specialists at a
distance [5]. This system was entirely developed at the Federal University of Santa Catarina - UFSC,
together with the Santa Catarina Sate Health Office (SES/SC). The technology was developed by the Cyclops
Research Group, that exists since 1998 at the Departamento de Informática e Estatística, Centro
Tecnológico at UFSC [6]. In 2009 the Cyclops Group, together with other research groups at UFSC and
UNIVALI, created the Brazilian Institute for Digital Convergence – INCoD.
On a national level, the Brazilian Telehalth Program was created by the Brazilian Health Ministry, with the
support of the Pan-American Health Organization - PAHO, in 2007. Santa Catarina, at that point, had a
coverage of more than 60 municipalities in its telemedicine programme and, for this reason, was one of the
9 States chosen to receive support for the implementation of a Telehealth Centre [6].
In 2010, with the integration of the Telemedicine and the Telehealth initiatives into one large software
platform and communication infrastructure, a unique integrated system was created, the Santa Catarina
State Integrated Telemedicine and Telehealth System – STT/SC. It offers distance examination reports in
diverse modalities and patient access to examinations, besides offering webconferences, teleconsultations
and distance courses for primary healthcare personnel through web-based and mobile platforms [6]. In
2016, the STT/SC achieved the mark of 5 million examinations, being present in all municipalities of the
State [6][7].

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Figure 1. Integrated Telehealth and Telemedicine Portal
Because of the State’s demographic composition, skin cancer represents a pathology with morbidity rates
of high epidemiologic relevance in the State of Santa Catarina in Brazil. In 2018, accordingly to the Brazilian
National Cancer Institute, in SC more than 36% of the new cancer cases will be skin neoplasms. The
incidence estimate of skin neoplams in SC for 2018 is 140.8 new cases for 100.000 inh. [8][9]. This makes
skin cancer the most common type of cancer in Santa Catarina.
INCA Estimatives SC 2018 New cases expected Incidence
(per 100.000 inh.)
Men Women Totals Men Women
Skin Cancer -
Non-Melanoma 5,800 3,680 9,480 163.16 104.18
Skin Cancer - Melanoma 270 240 510 7.58 6.68
Totals 6,070 3,920 9,990 170.74 110.86
General Totals (all
neoplasms) 15,970 11,380 27,350 449.1 321.96
% Skin Neoplasms 38.01% 34.45% 36.53%
Table 1. INCA estimatives for new cancer cases in Santa Catarina in 2018

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Research on Teledermatology in the context of the STT/SC started in 2006 with a project called “Sistema
para avaliação de indicadores sobre câncer de pele no estado de Santa Catarina utilizando Tele-
dermatologia” suported by FAPESC, the State’s public research foundation, and SES/SC. This project started
as a small pilot with 2 fishing communities in Florianópolis (Costa da Lagoa and Pântano do Sul) and one
community on the outskirts of the city (Monte Verde) [10].
Figure 2. Presentation of the Teledermatology Pilot Project at the Costa da Lagoa Primary Healthcare Center,
2007, by Dr. Senen Dyba Hauff, CEPON – Oncology Centre – Florianópolis (left of image) and (b) Costa
da Lagoa Village, an isolated fishig village in Florianópolis, as seen from the Lake Conceição.
This initiative grew, was extended by examination and patiernt flow protocols and integrated into the
routine examinations performed at the STT/SC.
The use of Teledermatology in the State was formalized with the deliberation 366/CIB/13 from August,
22nd, 2013. This deliberation, issued by the State Bipartite Health Mangement Committee (CIB/SC),
approved the usage of the Telediagnosys in Dermatology for the risk assessment and regulation of the
patient flow for the medical speciality of Dermatology. This had as a consequence that, in Santa Catarina,
patient triage and referral through the Brazilian National SISREG System started officially to be performed
through Telemedicine. This deliberation started to be followed in October, 2013 [11].
1.2 Patient Flow in Teledermatology
For the execution of a distance dermatology examination the capture and transmission of digital
photographs (panoramic images) or digital dermatoscopic images is necessary. This acquisition is
performed by a specially trained professional of the Primary Healthcare Service/Family Health Strategy
(APS/ESF). The acquired examination is then evaluated by dermatologist in reference centres [4].
In Santa Catarina, accordingly to the triage performed by the Teledermatologist, the cases undergo a risk
assessment and are classified in the colors red, yellow, green, blue or white.
This classification is performed accordingly to our classification protocol and to the diagnosys and
complexity of the case. Patients are then referred accordingly to this classification [7]:
• Red : serious illnesses that need to be referred imediatly to an emergency service. Patient referral
to an emergency service is agilized;

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• Yellow : referral directly to a specialized consultation with a dermatologist at a tertiary reference
centre or oncology centre. Patient referral to the correct treatment point is agilized;
• Green : referral to a consultation with a dermatologist at a regional outpatient clinic. Patient is
referred to a location nearby instead of a reference centre;
• Blue : cases that can be managed locally by the Primary Healthcare Service. No referral is
necessary;
• White : no medical intervention needed. No referral.
The figure below depicts the distance-finding reports issuing and risk assessment process.
Several studies present the effectiveness and feasibility of the use of Teledermatology for the diagnosis and
patient triage when compared to the traditional model of direct consultations with the dermatologist.
Diagnosis and findings concordance of both approaches has also been demonstrated. Described results
indicate benefits on costs, reduction of queues, diagnosis agility and effectiveness and correct diagnosis
[1],[12]-[18].
The effectiveness of this healthcare approach is not limited to non-severe illenesses. It can also show
benefits on the diagnosis and treatment of skin cancers [16][19]. Besides, the application of
Teledermatology is not limited to adults, paediatric patients can also benefit from it [20][21].
Besides intrinsic benefits to the medical, social and finace areas, there are also reports that describe that
the patients who received telemedicine care show a high satisfaction rate, consider it useful and are willing
to recomend it to friends and colleagues [28].
Figure 3. Patient flow of the Teledermatology at the STT/SC

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In the field of Public Health, the implementation of a public healthcare system that provides better
healthcare access to the citizen an important issue and ist effectiveness has to be guaranteed. Although
Teledermatology is a new approach, that is still not widely used in Brazil, international studies have shown
the effectiveness of Teledermatology on the diagnosis and treatment, being its diagnostic accuracy
equivalent to traditional face-to-face consultations [12]-[28]. There are, however, still very few studies that
compare the effectivenes to the costs of Teledermatology.

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2 System Efficiency and Travel Costs Avoidance
On the economic level, a good medical care system that is capable of rapidly and directly achieving all
necessary medical information for the adequate treatment of the patient is closely associated with the
treatment costs and efficiency of the system [27]. Although there are studies that show that the time spent
on a teledermatology consultation at a primary care facility is longer than on a consultation with a
dermatologist through the need to observe protocols, take more photographs and fill forms and protocols,
various factors are responsible for cost savings for the heakthcare system as a whole. Patient triage leads
to both direct and indirect cost savings. These costs are mainly avoided through the reduction of travel and
specialized consultation costs [22][23][24].
A study has shown that 43% of the travels can be avoided through patient triage[24].Another study shows a
cost reduction of up to US$ 480.00 per dermatologic patient, depending on the distance and duration of
the travel to a specialist [23][25].
The pre-selection of the patients, good quality clinic (panoramic) and dermatoscopic photographs of
potentially malignant lesions and a good communication ans software infrastructure are factors associated
to higher cost savings when employing tele-dermatological care. The planning of the patient flow and the
system operation are crucial points for the reduction of costs [26].
Through the patient triage at the Teledermatology service it is possible to refer a lesser number of patients
to the speciality services, quaranteeing that they will be referred directly to the adequate service and will
not have to go through several instances when they have a severe condition that needs e.g. urgent
oncological or emergency care. This should enhance the effectivity of the Primary Care services [27].
With this work we intend to show that Teledermatology is a tool capable of reducing both direct and
indirect costs to the Brazilian Public Heaslthcare System (Sistema Único de Saúde - SUS): a descentralized
patient triage infrastructure, with risk asessment and classification:
a) helps on the correct referral of the patients,
b) reduces travel costs, queues, waiting time and
c) also reduces intermediary appointments with unnecessary instances.
Besides, through reducing queues and offering the possibility to the patient to receive either local
treatment or direct referral to the final instance where she will be treated, we expect also to show that
Teledermatology enhances the accessibility to the healthcare services.
The approach to dermatologic telediagnostic employed in Santa Catarina can be a model able to be
implemented elsewhere, providing both efficaccy and cost-effectiveness [27].
One step in showing the general applicability of this patient trage approach is to demonstrate its cost-
effectiveness: how much direct costs can we reduce?
The question that we pose and seek to answer in this Technical Report is: What ist the direct finantial
impact for the Santa Catarina Health Office of the implementation of the patient triage through
Teledermatology?

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3 Method
This is an observational transversal epidemiologic study. This study worked only with secondary data, which
were collected directly from the servers of STT/SC using the Spatial Data Analysis tools provided by the
GISTelemed module of the STT/SC [29][30][31].
3.1 Studied Population
The population of this study encompassed all tele-dermatological examination protocols executed in the
context of the STT/SC durinh the years of 2014 to 2017 and the first half of 2018. This study is based upon
statistics gained from 83,100 teledermatological examination protocols that were performed at Primary
Healthcare Facilities in the context of the STT/SC during January, 2014 and June, 2018
3.2 Exclusion Criteria
Invalid examination protocols were excluded from the cost calculations.
Dermatologists working at the STT/SC consider examinations invalid when they were:
(a) acquired employing an image acquisition protocol in discordance with the diagnostic
hypothesis/pathology to be studied in the examination,
(b) the acquisition protocol was performed incorrectly or
(c) the images were of excessively poor quality.
In these cases, the responsible physicians are requested to contact the patients and perform the
examination again during the normal telemedicine process.
All data used in this study were previously evaluated by a dermatologist and had its validity flag already set
by the tele-dermatology personnel that analyzed the examination at the time of its acquisition.
We did not, in this study, retrieve images or findings reports from any examination in order to determine its
validity.
3.3 Biases
This study is based upon statistics from teledermatology data which were acquired over a time-span of 4.5
years by a large number of different healthcare professionals with diverse backgrounds, using a set of
different acquisition protocols, and posteriorly reviewed by different tele-dermatologists, also over a time-
span of 4.5 years. An observational bias cannot be excluded here.
The STT/SC has a continuous-training program: All healthcare professionals working with tele-dermatology
were trained on the correct execution of the acquisition protocols before each of the 313 examination
points started operating. These trainings are regularly refreshed. This should contribute to an
homogeneous performing of the protocols and the reduction of potential observational biases.

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3.4 Variables
For the generation of the cost-savings estimates presented in this work, the following variables were taken
into consideration:
Table 2. Study variables
Variable Dependent/
Independent Type Unit
Referral Independent Icotomic
qualitative Yes or No
Cost Dependent Continuous
quantitative
R$
Transportation Dependent Continuous
quantitative
R$
Per diem Dependent Continuous
quantitative R$
Accomodation Dependent Continuous
quantitative R$
Aoccompaining person
transportation Dependent Continuous
quantitative R$
Aoccompaining person per
diem Dependent Continuous
quantitative R$
Aoccompaining person
accomodation Dependent Continuous
quantitative R$
Origin Dependent Nominal
qualitative Originating Location
Distance Dependent Continuous
quantitative Km
Specialist consultation Dependent Dicotomic
qualitative Yes or No
Primary Care consultation Dependent Dicotomic
qualitative Yes or No
Consultation need Dependent Dicotomic
qualitative Yes or No
Source: [29]

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3.5 Data Collection
3.5.1 Procedures
Data collection was performed through electronic access to the STT/SC Telemedicine and Telehealth
platform available at https://telemedicina.saude.sc.gov.br/rctm/ using the login credentials of the authors.
Collected statistics were exported as spreadsheets, imported into a spreadsheet tool (Microsoft Excel) and
used for calculation the cost and cost-savings estimations and the generation of the graphics provided in
the next chapters.
3.5.2 Data Collection Instrument: GISTelemed
GISTelemed is an information and data visualization and recovery mechanism, integrated into our STT/SC
telemedicine infrastructure. It supports the indexing, retrieving and displaying georeferenced information
on a map or aerial images. The retrieval mechanism indexes structured data, semi-structured and DICOM
SR objects, allowing to perform several epidemiological analyses and plot them on a map or aerial image
[29][30][31].
As an example, the image below shows the distribution of skin cancer patients that were referred directly
from primary healthcare to an oncological clinic (Code Yellow) in the Itajaí River Valley in 2017:
Municipalities that have more than 1 primary healthcare facility are plotted as Voronoi diagrams, showing
different incidences per area. In order to generate this image we took a large timespan, but we could have
chosen daily data and have plotted it on dynamic timeline-based map.
The next image shows the same data, plotted as a heat map:

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The figure below presents another example of the Spatial Epidemiology modes of GISTelemed, showing
occurrences for the year of 2015 of Second Opinion Requests by Family Doctors as a heta map and as
ocurrence bubbles (a and b) and Dermatology Triages that resulted in codes Yellow (direct referral to
specialized care) and Red (immediate hospitalization). (c) shows an overview of the Municipalities of the
the Eastern Area of Santa Catarina and (d) depicts a detailed view of Santa Catarina Island and the Greater
Florianópolis Region.

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Results are also shown as graphics and tables. The figure below shows an example where the search results
for the association between four different variables and skin cancer are shown: sex and comorbidities (as
pie charts) and color and morphology (as tables):
The GISTelemed tool also allows the real-time monitoring of events ocurring on the Telemedicine and the
Telehealth networks and, more recently, all pacient referral requests (TFD), as shown in the figure below.
We call this operation mode “Situation Room”. In its present version, the system offers a fixed pallete of
events to be monitored. Events are organized per originating Primary Healthcare Facility. Last event is
shown in a pop-up window, as shown below:

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3.5.3 Data Sources for Cost Variables
Para o cálculo do custo direto da implantação da teledermatologia, foram usados dados do TFD e do
SIGTAP, os custos por procedimento estão descritos na Table 2.
Table 3. Direct costs elements of dermatological care per patient - Santa Catarina.
Procedure
SIGTAP Code
Cost (R$)
Consulta com
Especialista/Specialist Consultation
03.01.01.007-2
10,00
Deslocamento a cada
50km/Travel costs coverage for each 50k
travelled
08.03.01.012.5
4,95
Deslocamento a cada 50km (do
acompanhante)/Travel costs
coverage of the travel companion for each 50k travelled
08.03.01.010.9
4,95
Diária sem
pernoite/Per diem
08.03.01.002.8
8,40
Diária com
pernoite/Per diem with overnight
08.03.01.001.0
24,75
Diária sem pernoite para
acompanhante/Per diem for the travel
companion
08.03.01.005.2
8,40
Diária com pernoite para
acompanhante/Per diem with
overnight for the travel companion
08.03.01.004.4
24,75
Source: Authors,
2016.
3.6 Travel Distance Estimation
For the purpose of the estimation of the distance to be travelled by a patient for a specialized consultation
when referred, we took the division of the State into Healthcare Macro-Regions and considered the
distance from the main city of each Macro-Region to Florianópolis as being the mean distance to be
travelled by a patient from that Region to a specialist.
The figure below shows th division of the State into Healthcare Macro-Regions and the routes from
florianópolis to each of the main cities of each Region.

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Figure 4. Division of the State in Healthcare Macro-Regions and main travelling routes to Florianópolis from each
Macro-Region.

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3.7 Data Sources and Coverage
Data was always collected using GISTelemed. The data sources that fed our study were limited to the
primary healthcare facilities (USBs) that were linked to the Teledermatology Network of the STT/SC and had
actually implemented the service.
The implementation of Teldermatology Points at Primary Healthcare Facilities (UBSs) during the years 2014
– 2018 was progressive and the schedule that was followed for the implementation at the various UBSs is
shown in the table below. At the end of 2013 we already had a set of 56 USBs in 56 municipalities that
consisted of our extended pilot-test set. By the beginning of 2014 we started a systematic process of
extending this network, aimig at 100% coverage of the State, with the implementation of 258 new
Teledermatology points at UBSs in 229 municipalities throughout the State.By the end of the Study, we had
313 points implemented in 286 of the 295 Municipalites of the State. 16 of these new Teledermatology
point were implemented in prisons.
Implementation
Date (D/M/Y) Municipality Aditional Information
31/01/2014 Santo Amaro da Imperatriz
28/02/2014 Cunha Porã
27/03/2014 Sangão
10/04/2014 Blumenau
10/04/2014 Blumenau Aditional Point
10/04/2014 Blumenau Aditional Point
10/04/2014 Blumenau Aditional Point
01/05/2014 Balneário Arroio do Silva
21/05/2014 Balneário Gaivota
03/06/2014 Joinville
03/06/2014 Joinville Aditional Point
18/06/2014 Palhoça
07/08/2014 Leoberto L|eal
21/08/2014 Lebon Régis
18/09/2014 Imbuia
30/09/2014 São Carlos
01/10/2014 Três Barras
22/10/2014 Lacerdópolis
11/11/2014 Tijucas
15/11/2014 Florianópolis
28/11/2014 Botuverá
12/12/2014 Sul Brasil
18/02/15
Tigrinhos
24/02/15
Flor do Sertão
01/03/15
Blumenau
Aditional Point

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01/03/15
Blumenau
Aditional Point
01/03/15
Blumenau
Aditional Point
16/03/15
Armazém
16/03/15
Grão Pará
16/03/15
Rio Fortuna
16/03/15
São Ludgero
16/03/15
São Martinho
18/03/15
Jaguaruna
20/03/15
Bela Vista do Toldo
20/03/15
Irineópolis
20/03/15
Major Vieira
26/03/15
Jacinto Machado
31/03/15
Florianópolis
Aditional Point
01/04/15
Florianópolis
Aditional Point
01/04/15
Florianópolis
Aditional Point
11/04/15
Canelinha
15/04/15
Atalanta
15/04/15
Modelo
15/04/15
Pedras Grandes
23/04/15
Ouro
29/04/15
Laguna
11/05/15
Capivari de Baixo
14/05/15
Ermo
14/05/15
Maracajá
14/05/15 Meleiro
14/05/15
Morro Grande
14/05/15
Passo de Torres
14/05/15
Praia Grande
14/05/15
Santa Rosa do Sul
14/05/15
São João do Sul
14/05/15
Timbé do Sul
14/05/15
Turvo
20/05/15
Rio das Antas
21/05/15
Campo Alegre
21/05/15
Itaiópolis
21/05/15
Papanduva
21/05/15
Rio Negrinho
21/05/15
São Bento do Sul
28/05/15
Gravatal

Direct Impact on Costs of the Teledermatology-Centered Patient Triage
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28/05/15
São Miguel da Boa Vista
01/06/15
Monte Carlo
15/06/15
Rancho Queimado
15/06/15
Treze de Maio
17/06/15
Imaruí
17/06/15
Lebon Régis
19/06/15
Abdon Batista
19/06/15
Brunópolis
19/06/15
Ibiam
19/06/15
Vargem
19/06/15
Zortéa
22/06/15
Águas Mornas
24/06/15
Balneário Rincão
24/06/15
Cocal do Sul
24/06/15
Forquilhinha
24/06/15
Içara
24/06/15
Jardinópolis
24/06/15
Lauro Muller
24/06/15
Morro da Fumaça
24/06/15
Nova Veneza
24/06/15
Siderópolis
24/06/15
Treviso
24/06/15
Urussanga
26/06/15
Campo Belo do Sul
30/06/15
Pescaria Brava
14/07/15
Ascurra
14/07/15
Benedito Novo
14/07/15
Doutor Pedrinho
14/07/15
Guabiruba
14/07/15
Rio dos Cedros
14/07/15
Rodeio
15/07/15
Cerro Negro
16/07/15
Painel
20/07/15
Frei Rogério
20/07/15
Macieira
20/07/15
Massaranduba
20/07/15
Monte Castelo
20/07/15 Ponte Alta do Norte
20/07/15
Presidente Nereu

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20/07/15
Santa Cecília
21/07/15
São Cristovão do Sul
22/07/15
Brusque
25/07/15
Lontras
30/07/15
Angelina
01/08/15
Petrolândia
06/08/15
Urupema
11/08/15
Apiúna
18/08/15
Presidente Castello Branco
21/08/15
Major Gercino
25/08/15
Arroio Trinta
25/08/15
Iomerê
25/08/15
Pinheiro Preto
25/08/15
Salto Veloso
25/08/15
Timbó Grande
03/09/15
Paulo Lopes
03/09/15
Porto Belo
04/09/15
Antônio Carlos
15/09/15
Anita Garibaldi
15/09/15
Capão Alto
15/09/15
Correia Pinto
15/09/15
Otacílio Costa
15/09/15
Rio Rufino
15/09/15
São José do Cerrito
16/09/15
Bocaina do Sul
16/09/15
Bom Jardim da Serra
16/09/15
Bom Retiro
16/09/15
Palmeira
16/09/15
Urubici
05/10/15
Pinhalzinho
08/10/15
Faxinal dos Guedes
08/10/15
Governador Celso Ramos
16/10/15
Águas de Chapecó
16/10/15
Águas Frias
16/10/15
Arvoredo
16/10/15
Caibi
16/10/15
Catanduvas
16/10/15 Caxambu do Sul
16/10/15
Chapecó
Aditional Point

Direct Impact on Costs of the Teledermatology-Centered Patient Triage
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16/10/15
Chapecó
Aditional Point
16/10/15
Cordilheira Alta
16/10/15
Coronel Freitas
16/10/15
Cunhataí
16/10/15
Erval Velho
16/10/15
Formosa do Sul
16/10/15
Guatambú
16/10/15
Ibicaré
16/10/15
Irati
16/10/15
Jaborá
16/10/15
Luzerna
16/10/15
Nova Erechim
16/10/15
Nova Itaberaba
16/10/15
Paial
16/10/15
Planalto Alegre
16/10/15
Riqueza
16/10/15
Santiago do Sul
16/10/15 Serra Alta
16/10/15
União do Oeste
19/10/15
Bom Jesus
19/10/15 Coronel Martins
19/10/15
Entre Rios
19/10/15
Galvão
19/10/15
Ipuaçu
19/10/15
Jupiá
19/10/15
Lajeado Grande
19/10/15
Marema
19/10/15
Novo Horizonte
19/10/15
Ouro Verde
19/10/15
Passos Maia
19/10/15
Ponte Serrada
19/10/15
São Bernardino
19/10/15
São Domingos
19/10/15
Vargeão
21/10/15
Anchieta
21/10/15
Bandeirante
21/10/15
Barra Bonita
21/10/15
Bom Jesus do Oeste
21/10/15
Descanso

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21/10/15
Guaraciaba
21/10/15
Guarujá do Sul
21/10/15
Iporã do Oeste
21/10/15
Iraceminha
21/10/15
Mondaí
21/10/15
Princesa
21/10/15
Romelândia
21/10/15
Saltinho
21/10/15
Santa Helena
21/10/15
Santa Terezinha do Progresso
21/10/15
São João do Oeste
21/10/15
São José do Cedro
21/10/15
Saudades
21/10/15
Tunápolis
04/11/15
Arabutã
09/11/15
Agronômica
12/11/15
São João do Itaperiú
20/11/15
Ponte Alta
23/11/15
Aurora
24/11/15
Corupá
24/11/15
Massaranduba
24/11/15
Schroeder
26/11/15
Alto Bela Vista
26/11/15
Ipira
26/11/15
Irani
26/11/15
Lindóia do Sul
26/11/15
Peritiba
26/11/15
Piratuba
26/11/15
São José
26/11/15
São José
Aditional Point
30/11/15
Araquari
30/11/15
Balneário Barra do Sul
30/11/15
Barra Velha
30/11/15
Garuva
30/11/15
Itapoá
07/12/15
Belmonte
27/07/16
Trombudo Central
02/08/16
Laguna
Prisional - Unidade Prisional Avançada Laguna
04/08/16
Joinville
Prisional - Presídio Regional de Joinville

Direct Impact on Costs of the Teledermatology-Centered Patient Triage
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12/12/16
Rio do Oeste
02/03/17
Tangará
21/03/17
Pouso Redondo
24/03/17
José Boiteux
04/04/17
Camboriú
04/04/17
Itajaí
11/04/17
Chapadão do Lageado
11/04/17
Vidal Ramos
18/04/17
Bombinhas
18/04/17
Mirim Doce
18/04/17
Presidente Getúlio
02/05/17
Balneário Camboriú
02/05/17
Balneário Piçarras
02/05/17
Vitor Meireles
16/05/17
Dona Emma
16/05/17
Santa Terezinha
16/05/17
São Bonifácio
23/05/17
Braço do Trombudo
23/05/17
Ilhota
13/06/17
Navegantes
13/06/17
Salete
20/06/17
Itapema
01/08/17
Luiz Alves
03/08/17
Florianópolis
Prisional - Penitenciária de Florianópolis
09/08/17
Joinville
Prisional - Penitenciária Industrial de Joinville
15/08/17
Tubarão
Prisional - Presídio Masculino de Tubarão
16/08/17
Criciúma
Prisional - Penitenciária Sul
17/08/17
Imbituba
Prisional - Unidade Prisional Avançada - Imbituba
22/08/17 Canoinhas
Prisional - Unidade Prisional Avançada -
Canoinhas
23/08/17 Porto União
Prisional - Unidade Prisional Avançada - Porto
União
24/08/17
Mafra
Prisional - Presídio Regional de Mafra
09/11/17
Blumenau
Prisional - Penitenciária Industrial de Blumenau
14/11/17
Concórdia
Prisional - Presídio Regional de Concórdia
16/11/17
Videira
Prisional - Unidade Prisional Avançada - Videira
05/12/17
São Cristovão do Sul
Prisional - Penitenciária da Região de Curitibanos
05/12/17 São Cristovão do Sul
Prisional - Penitenciária Industrial de São
Cristóvão do Sul

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06/12/17
Lages
Prisional - Presídio Regional de Lages
20/12/17
Santa Terezinha do Progresso
Table 4. Teledermatology points and date of implementtaion and first local team training
This teledermatology points implementation effort was performed mainly in 2015, with a second, much
smaller wave in 2017, as shown in the graphic below.
Figure 5. Number of municipalities (blue) and teledermatology facilities (red) active during the time frame of this
study.
3.8 Ethic Aspects
This study meets the disclosure control requirements of the Resolution 466/12 of the Brazilian National
Health Council (CNS), also observing the directives of beneficience, no maleficence, justice, equity and
autonomy. Only secondary data were retrieved with the GISTelemed module and used to generate the
statistics presented here.
All data were handled at a level of abstraction (Macro-Regions) where to map the data back to individual
patient events was considered impossible: no individual municipalities were considered in our statistics and
also no results were generated where only a few geographically circunscribed data about rare diseases are
presented. For these reasons we considered the generated statistics secure against mapping back to
individual patients and we decided not to introduce artificial perturbations into the data in order to
guarantee disclosure control.
This study benefits directly the patients of the Brazilian Public Healthcare System – SUS, and also patients
elsewhere, because the results presented here could be used in order to justifiy the implementation of a
Teledermatology service at a different location, contributing to the reduction of queues and waiting times
and also to a better quality of dermatological healthcare.
There are no conflicts of interest.
0
50
100
150
200
250
300
350
12345678910 11 12 1234567891011 12 1234567891011 12 12345678910 11 12 1 2 3 4 5 6
2014 2015 2016 2017 2018
Municipalities
Points

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4 Results
4.1 Overview
This study is based upon statistics from 83,100 teledermatological examination protocols that were
performed at Primary Healthcare Facilities in the context of the STT/SC between January, 2014 and June,
2018 and employed for patient triage. 91.25% of these protocols were considered correctly performed and
valid. From the point of view of their spatial distribution and validity, the tables below present an overview:
Table 5. Dermatoscopic Examinations (01/01/2014 to 30/06/2018)
Total
Valid
Invalid
83,100
75,832
7,268
100.00%
91.25%
8.75%
Table 6. Valid vs. Invalid dermatoscopic examination protocols per region and year
2014
2015
2016
2017
2018
Sum
Region
Valid Invalid Valid Invalid Valid Invalid Valid Invalid Valid Invalid Valid Invalid
Planalto
Norte 114 22 431 77 858 52 711 59 313 33 2,427 243
Foz do
Rio Itajaí
73 16 76 5 19 0 712 23 515 33 1,395 77
Serra
Catarin.
596 138 530 78 413 45 868 117 618 66 3,025 444
Vale do
Itajaí 909 343 3,750 497 5,752 416 6,981 383 3,460 282 20,852 1,921
Grande
Fpolis
525 201 2,551 379 4,684 335 4,717 270 2,896 259 15,373 1,444
Meio
Oeste
688 249 968 102 1,088 115 1,224 116 747 121 4,715 703
Sul 589 209 1,660 214 2,050 193 1,978 206 1,295 166 7,572 988
Nordeste 167 65 313 28 2,072 162 3,841 107 2,309 85 8,702 447
Grande
Oeste
557 225 1,021 123 4,486 275 4,017 245 1,690 133 11,771 1,001
TOTAL 4,218 1,468 11,300 1,503 21,422 1,593 25,049 1,526 13,843 1,178 75,832 7,268
Examinations were considered invalid when they were:
• acquired employing an image acquisition protocol in discordance with the diagnostic
hypothesis/pathology to be studied in the examination,
• the acquisition protocol was performed incorrectly or
• the images were of excessively poor quality.
In these cases the responsible physicians were requested to contact the patients and perform the
examination again.

INCoD/TELEMED.04.2018.E.01
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The proportion between valid and invalid examinations in time is show by the graphic below:
Figure 6. Proportion between valid and invalid examinations per year
From the point of view of origin of the examinations, the proportion of valid and invalid examinations is
given by the following graphic:
Figure 7. Proportion between valid and invalid examinations per Healthcare Macro-Region
1,468 1,503 1,593 1,526 1,178
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2014 2015 2016 2017 2018
Invalid
Valid
243 77 444 1,921 1,444 703 988 447 1,001
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Planalto
Norte
Foz do Rio
Itajaí
Serra
Catarin.
Vale do
Itajaí
Grande
Fpolis
Meio
Oeste
Sul Nordeste Grande
Oeste
Invalid
Valid

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The graphic and the table below present the general total examination numbers per region:
Figure 8. Examinations per Healthcare Macro-Region
Table 7. Examinations per Healthcare Macro-Region, and their percentages
Region
Totals
Percentage
Planalto Norte
2,670
3.21%
Foz do Rio Itajaí
1,472 1.77%
Serra Catarin.
3,469
4.17%
Vale do Itajaí
22,773
27.40%
Grande Fpolis
16,817
20.24%
Meio Oeste
5,418
6.52%
Sul
8,560 10.30%
Nordeste
9,149
11.01%
Grande Oeste
12,772
15.37%
The Macro-Region that performed the most tele-dermatology protocols was the Itajaí Valley Region, with
22,773 valid teledermatology examinations (27.40%). The Macro-Region that performed the least tele-
dermatology protocols was the Itajaí River Mouth Region, with 1,472 valid teledermatology examinations
(1.77%).
2,670
1,472
3,469
22,773
16,817
5,418
8,560 9,149
12,772
0
5,000
10,000
15,000
20,000
25,000
Planalto
Norte
Foz do Rio
Itajaí
Serra
Catarin.
Vale do
Itajaí
Grande
Fpolis
Meio Oeste Sul Nordeste Grande
Oeste
Totals

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75,832 Teledermaotlogy protocols were considered valid (91.25%), whereas 7,268 (8.75%) were considered
invalid. Reasons for invalidation of a protocol were:
(a) the selection of an examination/image acquisition protocol that was incompatible with the
pathology hypothesis,
(b) incorrect execution of the examination/image acquisition protocol or
(c) the acquisition of qualitatively unusable images (e.g. blurred, incorrectly exposed or out-of-focus
images).
A total of 33,112 patients (43.66% of the valid examinations) submitted to the tele-dermatological triage
could be treated locally and did not need to be referred. The Macro-Region where the most patients
benefited was the Itajaí Valley Region, where a total of 9,376 patients were not referred (28.32% of the not
referred). The Macro-Region where the least patients benefited was the Itajaí River Mouth Region, where
only 482 patients did not need to be referred (1.46% of the not referred).
Figure 9. Case-resolution capacity (resolubility) per year enabled at the primary care through tele-dermatology
From a point of view of relative numbers, the greatest impact on the resolubility or case-resolution capacity
of the primary healthcare was achieved in 2014, when a total of 78.71% of the patients submitted to triage
did not need to be referred. The lowest observed resolubility was during the year of 2015, when only
34.38% of the patients submitted to triage did not need to be referred. We ponder about these relative
numbers in the Discussion at the end of this report.
For the calculation of the direct healthcare costs reduction through Teledermatology patient triage we
employed data from the TFD and SIGTAP:
• When a triage determines that a patient should consultate a specialist, the cost of the consultation
is R$ 10.00;
• Travel cost takes into consideration the mean distance of the main city of each Macro-Region to
Florianópolis;
78.71%
34.38%
55.05%
36.07%
44.24%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
2014 2015 2016 2017 2018
Resolubility
TOTAL

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• For each completed 50 Km a cost of R$ 4.95 is computed;
• Referred patients receive per diem:
o If they have to spend the night, this per diem is R$ 24.75
o If not, the per diem is R$8.40)
• For patients that cannot travel alone, the per diem amounts are doubled in order to cover the
expenses of the accompaining person.
• For patients referred inside the Macro-Region of Greater Florianópolis there are almost no
expenses covered.
Based upon the individual costs listed in Table 3 we calculated the costs that all patients that were not
referred would have generated if the Teledermatology did not exist. For this computation we considered
that all dermatological patients in the Public Healthcare System would have been referred, as had been the
practice before patient triage through Teledermatology was implemented in Santa Catarina.
We present the indidual calculations for each year of this study in Table 9 to Table 22, presenting the upper
and lower boundaries of the cost estimations. The upper boundary supposes none of the patients can
travel alone and expenses have to be calculated for an accompaining person for all patients. The lower
boundary supposes all patients are able to travel alone. Table 23 at pg.55 presents an overview of the
global costs for the 54 month period of this study. All tables stratify the costs per Macro-Region and also
present a set of consolidated values.
From the point of view of the absolute savings generated by the Teledermatology service, the total direct
savings in travel and consultation costs generated during the 54 month period of this study is an amount
ranging between R$3,294,421.90 and R$1,522,869.10. The Macro-Region that most profited from the
triage through the Teledermatology service is the Greater West Region with savings ranging between
R$961,750.20 and R$507,845.10. The least benefitted Macro-Region is the Itajaí River Mouth Region with
savings ranging from R$38,222.60 to R$13,640.60.

INCoD/TELEMED.04.2018.E.01
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4.2 2014
Table 8. Examinations, referrals and resolubility data for 2014
2014
Region Teledermatology
Examinations Referrals Nr. not
referred Resolubility
Average Dist.
to Florianópolis
(KM)
Planalto Norte 114 41 73 64.04% 307,80
Foz do Rio Itajaí 73 25 48 65.75% 97,60
Serra Catarin. 596 202 394 66.11% 226,10
Vale do Itajaí 909 229 680 74.81% 150,10
Grande Fpolis 525 28 497 94.67% 0,00
Meio Oeste 688 151 537 78.05% 390,50
Sul 589 107 482 81.83% 200,40
Nordeste 167 22 145 86.83% 179,00
Grande Oeste 557 93 464 83.30% 552,80
TOTAL
4,218
898
3,320
78.71%
0
100
200
300
400
500
600
700
800
900
1000
Planalto
Norte
Foz do
Rio Itajaí
Serra
Catarin.
Vale do
Itajaí
Grande
Fpolis
Meio
Oeste
Sul Nordeste Grande
Oeste
2014 Not referred
2014 Referrals

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4.2.1 Spatial Distribution: Healthcare Macro-Regions
4.2.2 Spatial Distribution: Municipalities

INCoD/TELEMED.04.2018.E.01
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4.2.3 Maximum Estimated Economy
Table 9. Maximum estimated costs reduction through Teledermatology in 2014
2014 Max. Cost Protocol (patient travelling with one accompanying person)
Individual Patients Costs
Totals
Total Costs
Totals
Region Nr. not
referred
Average
Dist. to
Florianópolis
(KM)
Specialist
consultation
Transpor-
tation
(TFD)
Patient
per
diem
Patient
companion
per diem
Specialist
consultation
Transpor-
tation (TFD)
Patient per
diem
Patient
companion
per diem
Planalto
Norte 73 307,80 R$10.00 R$69.30 R$24.75 R$24.75 R$128.80 R$730.00 R$5,058.90 R$1,806.75 R$1,806.75 R$9,402.40
Foz do
Rio Itajaí 48 97,60 R$10.00 R$19.80 R$24.75 R$24.75 R$79.30 R$480.00 R$950.40 R$1,188.00 R$1,188.00 R$3,806.40
Serra
Catarin. 394 226,10 R$10.00 R$49.50 R$24.75 R$24.75 R$109.00 R$3,940.00 R$19,503.00 R$9,751.50 R$9,751.50 R$42,946.00
Vale do
Itajaí 680 150,10 R$10.00 R$29.70 R$24.75 R$24.75 R$89.20 R$6,800.00 R$20,196.00 R$16,830.00 R$16,830.00 R$60,656.00
Grande
Fpolis 497 0,00 R$10.00 R$9.90 R$8.40 R$8.40 R$36.70 R$4,970.00 R$4,920.30 R$4,174.80 R$4,174.80 R$18,239.90
Meio
Oeste 537 390,50 R$10.00 R$79.20 R$24.75 R$24.75 R$138.70 R$5,370.00 R$42,530.40 R$13,290.75 R$13,290.75 R$74,481.90
Sul 482 200,40 R$10.00 R$39.60 R$24.75 R$24.75 R$99.10 R$4,820.00 R$19,087.20 R$11,929.50 R$11,929.50 R$47,766.20
Nordeste 145 179,00 R$10.00 R$39.60 R$24.75 R$24.75 R$99.10 R$1,450.00 R$5,742.00 R$3,588.75 R$3,588.75 R$14,369.50
Grande
Oeste 464 552,80 R$10.00 R$118.80 R$24.75 R$24.75 R$178.30 R$4,640.00 R$55,123.20 R$11,484.00 R$11,484.00 R$82,731.20
TOTAL
3,320
R$33,200.00
R$173,111.40
R$74,044.05
R$74,044.05
R$354,399.50

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4.2.4. Minimum Estimated Economy
Table 10. Minimum estimated costs reduction through Teledermatology in 2014
2014
Min. Cost Protocol (patient travelling alone)
Individual Patients Costs
Totals
Total Costs
Totals
Region Nr. not
referred
Average
Dist. to
Florianópolis
(KM)
Specialist
consultation
Transpor-
tation
(TFD)
Patient
per
diem
Patient
companion
per diem
Specialist
consultation
Transpor-
tation (TFD)
Patient per
diem
Patient
companion
per diem
Planalto
Norte 73 307,80 R$10.00 R$34.65 R$24.75 R$0.00 R$69.40 R$730.00 R$2,529.45 R$1,806.75 R$0.00 R$5,066.20
Foz do
Rio Itajaí 48 97,60 R$10.00 R$9.90 R$8.40 R$0.00 R$28.30 R$480.00 R$475.20 R$403.20 R$0.00 R$1,358.40
Serra
Catarin. 394 226,10 R$10.00 R$24.75 R$8.40 R$0.00 R$43.15 R$3,940.00 R$9,751.50 R$3,309.60 R$0.00 R$22,610.00
Vale do
Itajaí 680 150,10 R$10.00 R$14.85 R$8.40 R$0.00 R$33.25 R$6,800.00 R$10,098.00 R$5,712.00 R$0.00 R$22,610.00
Grande
Fpolis 497 0,00 R$10.00 R$4.95 R$8.40 R$0.00 R$23.35 R$4,970.00 R$2,460.15 R$4,174.80 R$0.00 R$11,604.95
Meio
Oeste 537 390,50 R$10.00 R$39.60 R$24.75 R$0.00 R$74.35 R$5,370.00 R$21,265.20 R$13,290.75 R$0.00 R$39,925.95
Sul 482 200,40 R$10.00 R$19.80 R$8.40 R$0.00 R$38.20 R$4,820.00 R$9,543.60 R$4,048.80 R$0.00 R$18,412.40
Nordeste 145 179,00 R$10.00 R$19.80 R$8.40 R$0.00 R$38.20 R$1,450.00 R$2,871.00 R$1,218.00 R$0.00 R$5,539.00
Grande
Oeste 464 552,80 R$10.00 R$59.40 R$24.75 R$0.00 R$94.15 R$4,640.00 R$27,561.60 R$11,484.00 R$0.00 R$43,685.60
TOTAL 3,320 R$33,200.00 R$86,555.70 R$45,447.90 R$0.00 R$165,203.60

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4.3 2015
Table 11. Examinations, referrals and resolubility data for 2015
2015
Region Teledermatology
Examinations Referrals Nr. not
referred Resolubility
Average Dist. to
Florianópolis
(KM)
Planalto Norte 431 255 176 40.84% 307.80
Foz do Rio
Itajaí 76 46 30 39.47% 97.60
Serra Catarin. 530 380 150 28.30% 226.10
Vale do Itajaí 3,750 2,447 1,303 34.75% 150.10
Gde Fpolis 2,551 1,543 1,008 39.51% 0.00
Meio Oeste 968 696 272 28.10% 390.50
Sul 1,660 1,140 520 31.33% 200.40
Nordeste 313 210 103 32.91% 179.00
Gde. Oeste 1,021 698 323 31.64% 552.80
TOTAL
11,300
7,415
3,885
34.38%
0
500
1000
1500
2000
2500
3000
3500
4000
Planalto
Norte
Foz do
Rio Itajaí
Serra
Catarin.
Vale do
Itajaí
Grande
Fpolis
Meio
Oeste
Sul Nordeste Grande
Oeste
2015 Not referred
2015 Referrals

Direct Impact on Costs of the Teledermatology-Centered Patient Triage
in the State of Santa Catarina
ISSN 2236-5281
40
4.3.1 Spatial Distribution: Healthcare Macro-Regions
4.3.2 Spatial Distribution: Municipalities

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41 ISSN 2236-5281
4.3.3 Maximum Estimated Economy
Table 12. Maximum estimated costs reduction through Teledermatology in 2015
2015
Max. Cost Protocol (patient travelling with one accompanying person)
Individual Patients Costs
Total/
patient
Total Costs
Totals
Region Nr. not
referred
Average
Dist. to
Florianópolis
(KM)
Specialist
consultation
Transpor-
tation
(TFD)
Patient
per
diem
Patient
companion
per diem
Specialist
consultation
Transpor-
tation (TFD)
Patient per
diem
Patient
companion
per diem
Planalto
Norte 176 307.80 R$10.00 R$69.30 R$24.75 R$24.75 R$128.80 R$1,760.00 R$12,196.80 R$4,356.00 R$4,356.00 R$22,668.80
Foz do
Rio Itajaí 30 97.60 R$10.00 R$19.80 R$24.75 R$24.75 R$79.30 R$300.00 R$594.00 R$742.50 R$742.50 R$2,379.00
Serra
Catarin. 150 226.10 R$10.00 R$49.50 R$24.75 R$24.75 R$109.00 R$1,500.00 R$7,425.00 R$3,712.50 R$3,712.50 R$16,350.00
Vale do
Itajaí 1,303 150.10 R$10.00 R$29.70 R$24.75 R$24.75 R$89.20 R$13,030.00 R$38,699.10 R$32,249.25 R$32,249.25 R$116,227.60
Gde
Fpolis 1,008 0.00 R$10.00 R$9.90 R$8.40 R$8.40 R$36.70 R$10,080.00 R$9,979.20 R$8,467.20 R$8,467.20 R$36,993.60
Meio
Oeste 272 390.50 R$10.00 R$79.20 R$24.75 R$24.75 R$138.70 R$2,720.00 R$21,542.40 R$6,732.00 R$6,732.00 R$37,726.40
Sul 520 200.40 R$10.00 R$39.60 R$24.75 R$24.75 R$99.10 R$5,200.00 R$20,592.00 R$12,870.00 R$12,870.00 R$51,532.00
Nordeste 103 179.00 R$10.00 R$39.60 R$24.75 R$24.75 R$99.10 R$1,030.00 R$4,078.80 R$2,549.25 R$2,549.25 R$10,207.30
Gde.
Oeste 323 552.80 R$10.00 R$118.80 R$24.75 R$24.75 R$178.30 R$3,230.00 R$38,372.40 R$7,994.25 R$7,994.25 R$57,590.90
TOTAL
3,885
R$38,850.00
R$153,479.70
R$79,672.95
R$79,672.95
R$351,675.60

Direct Impact on Costs of the Teledermatology-Centered Patient Triage
in the State of Santa Catarina
ISSN 2236-5281
42
4.3.4. Minimum Estimated Economy
Table 13. Minimum estimated costs reduction through Teledermatology in 2015
2015
Min. Cost Protocol (patient travelling alone)
Individual Patients Costs
Total/
patient
Total Costs
Totals
Region Nr. not
referred
Average
Dist. to
Florianópolis
(KM)
Specialist
consultation
Transpor-
tation
(TFD)
Patient
per
diem
Patient
companion
per diem
Specialist
consultation
Transpor-
tation (TFD)
Patient per
diem
Patient
companion
per diem
Planalto
Norte 176 307.80 R$10.00 R$34.65 R$24.75 R$0.00 R$69.40 R$1,760.00 R$6,098.40 R$4,356.00 R$0.00 R$12,214.40
Foz do
Rio Itajaí 30 97.60 R$10.00 R$9.90 R$8.40 R$0.00 R$28.30 R$300.00 R$297.00 R$252.00 R$0.00 R$849.00
Serra
Catarin. 150 226.10 R$10.00 R$24.75 R$8.40 R$0.00 R$43.15 R$1,500.00 R$3,712.50 R$1,260.00 R$0.00 R$6,472.50
Vale do
Itajaí 1,303 150.10 R$10.00 R$14.85 R$8.40 R$0.00 R$33.25 R$13,030.00 R$19,349.55 R$10,945.20 R$0.00 R$43,324.75
Gde
Fpolis 1,008 0.00 R$10.00 R$4.95 R$8.40 R$0.00 R$23.35 R$10,080.00 R$4,989.60 R$8,467.20 R$0.00 R$23,536.80
Meio
Oeste 272 390.50 R$10.00 R$39.60 R$24.75 R$0.00 R$74.35 R$2,720.00 R$10,771.20 R$6,732.00 R$0.00 R$20,223.20
Sul 520 200.40 R$10.00 R$19.80 R$8.40 R$0.00 R$38.20 R$5,200.00 R$10,296.00 R$4,368.00 R$0.00 R$19,864.00
Nordeste 103 179.00 R$10.00 R$19.80 R$8.40 R$0.00 R$38.20 R$1,030.00 R$2,039.40 R$865.20 R$0.00 R$3,934.60
Gde.
Oeste 323 552.80 R$10.00 R$59.40 R$24.75 R$0.00 R$94.15 R$3,230.00 R$19,186.20 R$7,994.25 R$0.00 R$30,410.45
TOTAL
3,885
R$38,850.00
R$76,739.85
R$45,239.85
R$0.00
R$160,829.70

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43 ISSN 2236-5281
4.4 2016
Table 14. Examinations, referrals and resolubility data for 2016
2016
Region Teledermatology
Examinations Referrals Nr. not
referred Resolubility
Average Dist.
to Florianópolis
(KM)
Planalto Norte 858 353 505 58.86% 307,80
Foz do Rio Itajaí 19 7 12 63.16% 97,60
Serra 413 113 300 72.64% 226,10
Vale do Itajaí 5,752 2,462 3,290 57.20% 150,10
Gde Fpolis 4,684 2,102 2,582 55.12% 0,00
Meio Oeste 1,088 543 545 50.09% 390,50
Sul 2,050 858 1,192 58.15% 200,40
Nordeste 2,072 1,062 1,010 48.75% 179,00
Gde Oeste 4,486 2,130 2,356 52.52% 552,80
TOTAL 21,422 9,630 11,792 55.05%
0
1000
2000
3000
4000
5000
6000
7000
2016 Not referred
2016 Referrals

Direct Impact on Costs of the Teledermatology-Centered Patient Triage
in the State of Santa Catarina
ISSN 2236-5281
44
4.4.1 Spatial Distribution: Healthcare Macro-Regions
4.4.2 Spatial Distribution: Municipalities

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45 ISSN 2236-5281
4.4.3 Maximum Estimated Economy
Table 15. Maximum estimated costs reduction through Teledermatology in 2016
2016
Max. Cost Protocol (patient travelling with one accompanying person)
Individual Patients Costs
Total/
patient
Total Costs
Totals
Region Nr. not
referred
Average Dist.
to
Florianópolis
(KM)
Specialist
consulta-
tion
Transpor-
tation
(TFD)
Patient
per diem
Patient
compani
on per
diem
Specialist
consultation
Transpor-tation
(TFD)
Patient per
diem
Patient
companion per
diem
Planalto
Norte 505 307,80 R$10.00 R$69.30 R$24.75 R$24.75 R$128.80 R$5,050.00 R$34,996.50 R$12,498.75 R$12,498.75 R$65,044.00
Foz do
Rio Itajaí 12 97,60 R$10.00 R$19.80 R$24.75 R$24.75 R$79.30 R$120.00 R$237.60 R$297.00 R$297.00 R$951.60
Serra 300 226,10 R$10.00 R$49.50 R$24.75 R$24.75 R$109.00 R$3,000.00 R$14,850.00 R$7,425.00 R$7,425.00 R$32,700.00
Vale do
Itajaí 3,290 150,10 R$10.00 R$29.70 R$24.75 R$24.75 R$89.20 R$32,900.00 R$97,713.00 R$81,427.50 R$81,427.50 R$293,468.00
Gde
Fpolis 2,582 0,00 R$10.00 R$9.90 R$8.40 R$8.40 R$36.70 R$25,820.00 R$25,561.80 R$21,688.80 R$21,688.80 R$94,759.40
Meio
Oeste 545 390,50 R$10.00 R$79.20 R$24.75 R$24.75 R$138.70 R$5,450.00 R$43,164.00 R$13,488.75 R$13,488.75 R$75,591.50
Sul 1,192 200,40 R$10.00 R$39.60 R$24.75 R$24.75 R$99.10 R$11,920.00 R$47,203.20 R$29,502.00 R$29,502.00 R$118,127.20
Nordeste 1,010 179,00 R$10.00 R$39.60 R$24.75 R$24.75 R$99.10 R$10,100.00 R$39,996.00 R$24,997.50 R$24,997.50 R$100,091.00
Gde
Oeste 2,356 552,80 R$10.00 R$118.80 R$24.75 R$24.75 R$178.30 R$23,560.00 R$279,892.80 R$58,311.00 R$58,311.00 R$420,074.80
TOTAL 11,792 R$117,920.00 R$583,614.90 R$249,636.30 R$249,636.30 R$1,200,807.50

Direct Impact on Costs of the Teledermatology-Centered Patient Triage
in the State of Santa Catarina
ISSN 2236-5281
46
4.4.4. Minimum Estimated Economy
Table 16. Minimum estimated costs reduction through Teledermatology in 2016
2016
Min. Cost Protocol (patient travelling alone)
Individual Patients Costs
Total/
patient
Total Costs
Totals
Region Nr. not
referred
Average
Dist. to
Florianópolis
(KM)
Specialist
consultation
Transpor-
tation
(TFD)
Patient
per
diem
Patient
companion
per diem
Specialist
consultation
Transpor-
tation (TFD)
Patient per
diem
Patient
companion
per diem
Planalto
Norte 505 307,80 R$10.00 R$34.65 R$24.75 R$0.00 R$69.40 R$5,050.00 R$17,498.25 R$12,498.75 R$0.00 R$35,047.00
Foz do
Rio Itajaí 12 97,60 R$10.00 R$9.90 R$8.40 R$0.00 R$28.30 R$120.00 R$118.80 R$100.80 R$0.00 R$339.60
Serra 300 226,10 R$10.00 R$24.75 R$8.40 R$0.00 R$43.15 R$3,000.00 R$7,425.00 R$2,520.00 R$0.00 R$12,945.00
Vale do
Itajaí 3,290 150,10 R$10.00 R$14.85 R$8.40 R$0.00 R$33.25 R$32,900.00 R$48,856.50 R$27,636.00 R$0.00 R$109,392.50
Gde
Fpolis 2,582 0,00 R$10.00 R$4.95 R$8.40 R$0.00 R$23.35 R$25,820.00 R$12,780.90 R$21,688.80 R$0.00 R$60,289.70
Meio
Oeste 545 390,50 R$10.00 R$39.60 R$24.75 R$0.00 R$74.35 R$5,450.00 R$21,582.00 R$13,488.75 R$0.00 R$40,520.75
Sul 1,192 200,40 R$10.00 R$19.80 R$8.40 R$0.00 R$38.20 R$11,920.00 R$23,601.60 R$10,012.80 R$0.00 R$45,534.40
Nordeste 1,010 179,00 R$10.00 R$19.80 R$8.40 R$0.00 R$38.20 R$10,100.00 R$19,998.00 R$8,484.00 R$0.00 R$38,582.00
Gde
Oeste 2,356 552,80 R$10.00 R$59.40 R$24.75 R$0.00 R$94.15 R$23,560.00 R$139,946.40 R$58,311.00 R$0.00 R$221,817.40
TOTAL 11,792 R$117,920.00 R$291,807.45 R$154,740.90 R$0.00 R$564,468.35

INCoD/TELEMED.04.2018.E.01
47 ISSN 2236-5281
4.5 2017
Table 17. Examinations, referrals and resolubility data for 2017
2017
Region Teledermatology
Examinations Referrals Nr. not
referred Resolubility
Average Dist.
to Florianópolis
(KM)
Planalto Norte 711 477 234 32.91% 307,80
Foz do Rio Itajaí 712 499 213 29.92% 97,60
Serra 868 584 284 32.72% 226,10
Vale do Itajaí 6,981 4,195 2,786 39.91% 150,10
Gde Fpolis 4,717 3,003 1,714 36.34% 0,00
Meio Oeste 1,224 916 308 25.16% 390,50
Sul 1,978 1,388 590 29.83% 200,40
Nordeste 3,841 2,481 1,360 35.41% 179,00
Gde Oeste 4,017 2,470 1,547 38.51% 552,80
TOTAL 25,049 16,013 9,036 36.07%
0
1000
2000
3000
4000
5000
6000
7000
8000
Planalto
Norte
Foz do
Rio Itajaí
Serra
Catarin.
Vale do
Itajaí
Grande
Fpolis
Meio
Oeste
Sul Nordeste Grande
Oeste
2017 Not referred
2017 Referrals

Direct Impact on Costs of the Teledermatology-Centered Patient Triage
in the State of Santa Catarina
ISSN 2236-5281
48
4.5.1 Spatial Distribution: Healthcare Macro-Regions
4.5.2 Spatial Distribution: Municipalities

INCoD/TELEMED.04.2018.E.01
49 ISSN 2236-5281
4.5.3 Maximum Estimated Economy
Table 18. Maximum estimated costs reduction through Teledermatology in 2017
2017
Max. Cost Protocol (patient travelling with one accompanying person)
Individual Patients Costs
Total/
patient
Total Costs
Totals
Region Nr. not
referred
Average
Dist. to
Florianópolis
(KM)
Specialist
consultation
Transpor-
tation
(TFD)
Patient
per
diem
Patient
companion
per diem
Specialist
consultation
Transpor-
tation (TFD)
Patient per
diem
Patient
companion
per diem
Planalto
Norte 234 307,80 R$10.00 R$69.30 R$24.75 R$24.75 R$128.80 R$2,340.00 R$16,216.20 R$5,791.50 R$5,791.50 R$30,139.20
Foz do
Rio Itajaí 213 97,60 R$10.00 R$19.80 R$24.75 R$24.75 R$79.30 R$2,130.00 R$4,217.40 R$5,271.75 R$5,271.75 R$16,890.90
Serra 284 226,10 R$10.00 R$49.50 R$24.75 R$24.75 R$109.00 R$2,840.00 R$14,058.00 R$7,029.00 R$7,029.00 R$30,956.00
Vale do
Itajaí 2,786 150,10 R$10.00 R$29.70 R$24.75 R$24.75 R$89.20 R$27,860.00 R$82,744.20 R$68,953.50 R$68,953.50 R$248,511.20
Gde
Fpolis 1,714 0,00 R$10.00 R$9.90 R$8.40 R$8.40 R$36.70 R$17,140.00 R$16,968.60 R$14,397.60 R$14,397.60 R$62,903.80
Meio
Oeste 308 390,50 R$10.00 R$79.20 R$24.75 R$24.75 R$138.70 R$3,080.00 R$24,393.60 R$7,623.00 R$7,623.00 R$42,719.60
Sul 590 200,40 R$10.00 R$39.60 R$24.75 R$24.75 R$99.10 R$5,900.00 R$23,364.00 R$14,602.50 R$14,602.50 R$58,469.00
Nordeste 1,360 179,00 R$10.00 R$39.60 R$24.75 R$24.75 R$99.10 R$13,600.00 R$53,856.00 R$33,660.00 R$33,660.00 R$134,776.00
Gde
Oeste 1,547 552,80 R$10.00 R$118.80 R$24.75 R$24.75 R$178.30 R$15,470.00 R$183,783.60 R$38,288.25 R$38,288.25 R$275,830.10
TOTAL 9,036 R$90,360.00 R$419,601.60 R$195,617.10 R$195,617.10 R$901,195.80

Direct Impact on Costs of the Teledermatology-Centered Patient Triage
in the State of Santa Catarina
ISSN 2236-5281
50
4.5.4. Minimum Estimated Economy
Table 19. Minimum estimated costs reduction through Teledermatology in 2017
2017
Min. Cost Protocol (patient travelling alone)
Individual Patients Costs
Total/
patient
Total Costs
Totals
Region Nr. not
referred
Average
Dist. to
Florianópolis
(KM)
Specialist
consultation
Transpor-
tation
(TFD)
Patient
per
diem
Patient
companion
per diem
Specialist
consultation
Transpor-
tation (TFD)
Patient per
diem
Patient
companion
per diem
Planalto
Norte 234 307,80 R$10.00 R$34.65 R$24.75 R$0.00 R$69.40 R$2,340.00 R$8,108.10 R$5,791.50 R$0.00 R$16,239.60
Foz do
Rio Itajaí 213 97,60 R$10.00 R$9.90 R$8.40 R$0.00 R$28.30 R$2,130.00 R$2,108.70 R$1,789.20 R$0.00 R$6,027.90
Serra 284 226,10 R$10.00 R$24.75 R$8.40 R$0.00 R$43.15 R$2,840.00 R$7,029.00 R$2,385.60 R$0.00 R$12,254.60
Vale do
Itajaí 2,786 150,10 R$10.00 R$14.85 R$8.40 R$0.00 R$33.25 R$27,860.00 R$41,372.10 R$23,402.40 R$0.00 R$92,634.50
Gde
Fpolis 1,714 0,00 R$10.00 R$4.95 R$8.40 R$0.00 R$23.35 R$17,140.00 R$8,484.30 R$14,397.60 R$0.00 R$40,021.90
Meio
Oeste 308 390,50 R$10.00 R$39.60 R$24.75 R$0.00 R$74.35 R$3,080.00 R$12,196.80 R$7,623.00 R$0.00 R$22,899.80
Sul 590 200,40 R$10.00 R$19.80 R$8.40 R$0.00 R$38.20 R$5,900.00 R$11,682.00 R$4,956.00 R$0.00 R$22,538.00
Nordeste 1,360 179,00 R$10.00 R$19.80 R$8.40 R$0.00 R$38.20 R$13,600.00 R$26,928.00 R$11,424.00 R$0.00 R$51,952.00
Gde
Oeste 1,547 552,80 R$10.00 R$59.40 R$24.75 R$0.00 R$94.15 R$15,470.00 R$91,891.80 R$38,288.25 R$0.00 R$145,650.05
TOTAL 9,036 R$90,360.00 R$209,800.80 R$110,057.55 R$0.00 R$410,218.35

INCoD/TELEMED.04.2018.E.01
51 ISSN 2236-5281
4.6 Jan.-June 2018
Table 20. Examinations, referrals and resolubility data for 2018
Jan.-June 2018
Region
Telederma-
tology
Examinations
Invalid
Exams Referrals Nr. not
referred
Resolu-
bility
Average
Dist.
Florianó-
polis (KM)
Planalto Norte 313 33 183 130 41.53% 307,80
Foz do Rio
Itajaí 515 33 336 179 34.76% 97,60
Serra Catarin. 618 66 415 203 32.85% 226,10
Vale do Itajaí 3,460 282 2,143 1,317 38.06% 150,10
Gde Fpolis 2,896 259 1,742 1,154 39.85% 0,00
Meio Oeste 747 121 495 252 33.73% 390,50
Sul 1,295 166 837 458 35.37% 200,40
Nordeste 2,309 85 1,627 682 29.54% 179,00
Gde Oeste 1,690 133 986 704 41.66% 552,80
TOTAL 13,843 1,178 8,764 5,079 36.69%
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
Planalto
Norte
Foz do
Rio Itajaí
Serra
Catarin.
Vale do
Itajaí
Grande
Fpolis
Meio
Oeste
Sul Nordeste Grande
Oeste
2018 Not referred
2018 Referrals

Direct Impact on Costs of the Teledermatology-Centered Patient Triage
in the State of Santa Catarina
ISSN 2236-5281
52
4.6.1 Spatial Distribution: Healthcare Macro-Regions
4.6.2 Spatial Distribution: Municipalities

INCoD/TELEMED.04.2018.E.01
53 ISSN 2236-5281
4.6.3 Maximum Estimated Economy
Table 21. Maximum estimated costs reduction through Teledermatology in the first half of 2018
2018
Max. Cost Protocol (patient travelling with one accompanying person)
Individual Patients Costs
Total/
patient
Total Costs
Totals
Region Nr. not
referred
Average
Dist.
Florianó-
polis
(KM)
Specialist
consul-
tation
Transpor-
tation
(TFD)
Patient
per
diem
Patient
companion
per diem
Specialist
consul-
tation
Transpor-
tation (TFD)
Patient per
diem
Patient
companion
per diem
Planalto
Norte 130 307,80 R$10.00 R$69.30 R$24.75 R$24.75 R$128.80 R$1,300.00 R$9,009.00 R$3,217.50 R$3,217.50 R$16,744.00
Foz do
Rio Itajaí 179 97,60 R$10.00 R$19.80 R$24.75 R$24.75 R$79.30 R$1,790.00 R$3,544.20 R$4,430.25 R$4,430.25 R$14,194.70
Serra
Catarin. 203 226,10 R$10.00 R$49.50 R$24.75 R$24.75 R$109.00 R$2,030.00 R$10,048.50 R$5,024.25 R$5,024.25 R$22,127.00
Vale do
Itajaí 1,317 150,10 R$10.00 R$29.70 R$24.75 R$24.75 R$89.20 R$13,170.00 R$39,114.90 R$32,595.75 R$32,595.75 R$117,476.40
Gde
Fpolis 1,154 0,00 R$10.00 R$9.90 R$8.40 R$8.40 R$36.70 R$11,540.00 R$11,424.60 R$9,693.60 R$9,693.60 R$42,351.80
Meio
Oeste 252 390,50 R$10.00 R$79.20 R$24.75 R$24.75 R$138.70 R$2,520.00 R$19,958.40 R$6,237.00 R$6,237.00 R$34,952.40
Sul 458 200,40 R$10.00 R$39.60 R$24.75 R$24.75 R$99.10 R$4,580.00 R$18,136.80 R$11,335.50 R$11,335.50 R$45,387.80
Nordeste 682 179,00 R$10.00 R$39.60 R$24.75 R$24.75 R$99.10 R$6,820.00 R$27,007.20 R$16,879.50 R$16,879.50 R$67,586.20
Gde
Oeste 704 552,80 R$10.00 R$118.80 R$24.75 R$24.75 R$178.30 R$7,040.00 R$83,635.20 R$17,424.00 R$17,424.00 R$125,523.20
TOTAL 5,079 R$50,790.00 R$221,878.80 R$106,837.35 R$106,837.35 R$486,343.50

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4.6.4. Minimum Estimated Economy
Table 22. Maximum estimated costs reduction through Teledermatology in the first half of 2018
2018
Min. Cost Protocol (patient travelling alone)
Individual Patients Costs
Total/
patient
Total Costs
Totals
Region Nr. not
referred
Average
Dist.
Florianó-
polis
(KM)
Specialist
consul-
tation
Transpor-
tation
(TFD)
Patient
per
diem
Patient
companion
per diem
Specialist
consul-
tation
Transpor-
tation (TFD)
Patient per
diem
Patient
companion
per diem
Planalto
Norte
130 307,80 R$10.00 R$34.65 R$24.75 R$0.00 R$69.40 R$1,300.00 R$4,504.50 R$3,217.50 R$0.00 R$9,022.00
Foz do
Rio Itajaí 179 97,60 R$10.00 R$9.90 R$8.40 R$0.00 R$28.30 R$1,790.00 R$1,772.10 R$1,503.60 R$0.00 R$5,065.70
Serra
Catarin.
203 226,10 R$10.00 R$24.75 R$8.40 R$0.00 R$43.15 R$2,030.00 R$5,024.25 R$1,705.20 R$0.00 R$8,759.45
Vale do
Itajaí
1,317 150,10 R$10.00 R$14.85 R$8.40 R$0.00 R$33.25 R$13,170.00 R$19,557.45 R$11,062.80 R$0.00 R$43,790.25
Gde
Fpolis
1,154 0,00 R$10.00 R$4.95 R$8.40 R$0.00 R$23.35 R$11,540.00 R$5,712.30 R$9,693.60 R$0.00 R$26,945.90
Meio
Oeste
252 390,50 R$10.00 R$39.60 R$24.75 R$0.00 R$74.35 R$2,520.00 R$9,979.20 R$6,237.00 R$0.00 R$18,736.20
Sul 458 200,40 R$10.00 R$19.80 R$8.40 R$0.00 R$38.20 R$4,580.00 R$9,068.40 R$3,847.20 R$0.00 R$17,495.60
Nordeste 682 179,00 R$10.00 R$19.80 R$8.40 R$0.00 R$38.20 R$6,820.00 R$13,503.60 R$5,728.80 R$0.00 R$26,052.40
Gde
Oeste
704 552,80 R$10.00 R$59.40 R$24.75 R$0.00 R$94.15 R$7,040.00 R$41,817.60 R$17,424.00 R$0.00 R$66,281.60
TOTAL 5,079 R$50,790.00 R$110,939.40 R$60,419.70 R$0.00 R$222,149.10

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4.7 Consolidated Cost Reduction Estimates
The table below provides an overview of the estimated cost reduction boundaries in dermatology patient care achieved through Teledermatology,
organized per year and per Healthcare Macro-Region
It is important to take in mind that:
• Maximum cost reduction = all referred patients would travel together with an accompaining person) and
• Minimum cost reduction = all referred patients would travel alone.
Table 23. Estimated cost reduction boundaries in dermatology patient care achieved through Teledermatology
2014
2015
2016
2017
2018
Totals
Region
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Max. Economy
Min. Economy
Planalto
Norte
R$9,402.40 R$5,066.20 R$22,668.80 R$12,214.40 R$65,044.00 R$35,047.00 R$30,139.20 R$16,239.60 R$16,744.00 R$9,022.00 R$143,998.40 R$77,589.20
Foz do Rio
Itajaí
R$3,806.40
R$1,358.40
R$2,379.00
R$849.00
R$951.60
R$339.60
R$16,890.90
R$6,027.90
R$14,194.70
R$5,065.70
R$38,222.60
R$13,640.60
Serra
Catarin.
R$42,946.00 R$22,610.00 R$16,350.00 R$6,472.50 R$32,700.00 R$12,945.00 R$30,956.00 R$12,254.60 R$22,127.00 R$8,759.45 R$145,079.00 R$63,041.55
Vale do
Itajaí
R$60,656.00
R$22,610.00
R$116,227.60
R$43,324.75
R$293,468.00
R$109,392.50
R$248,511.20
R$92,634.50
R$117,476.40
R$43,790.25
R$836,339.20
R$311,752.00
Grande
Fpolis R$18,239.90 R$11,604.95 R$36,993.60 R$23,536.80 R$94,759.40 R$60,289.70 R$62,903.80 R$40,021.90 R$42,351.80 R$26,945.90 R$255,248.50 R$162,399.25
Meio Oeste
R$74,481.90
R$39,925.95
R$37,726.40
R$20,223.20
R$75,591.50
R$40,520.75
R$42,719.60
R$22,899.80
R$34,952.40
R$18,736.20
R$265,471.80
R$142,305.90
Sul R$47,766.20 R$18,412.40 R$51,532.00 R$19,864.00 R$118,127.20 R$45,534.40 R$58,469.00 R$22,538.00 R$45,387.80 R$17,495.60 R$321,282.20 R$123,844.40
Nordeste
R$14,369.50
R$5,539.00
R$10,207.30
R$3,934.60
R$100,091.00
R$38,582.00
R$134,776.00
R$51,952.00
R$67,586.20
R$26,052.40
R$327,030.00
R$126,060.00
Grande
Oeste R$82,731.20 R$43,685.60 R$57,590.90 R$30,410.45 R$420,074.80 R$221,817.40 R$275,830.10 R$145,650.05 R$125,523.20 R$66,281.60 R$961,750.20 R$507,845.10
TOTAL
R$354,399.50
R$165,203.60
R$351,675.60
R$160,829.70
R$1,200,807.50
R$564,468.35
R$901,195.80
R$410,218.35
R$486,343.50
R$222,149.10
R$3,294,421.90
R$1,522,869.10
The relationships between the Macro-Regions and the maximum and minimum cost reduction estimates can be better visualized in the graphic
below. It depicts the maximum and minimum cost reduction estimates as bars, organized per Macro-Region, showing the value for the maximum cost
reduction estimate (dark green):

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The graphic below depicts the global maximum and minimum cost reduction estimates per year. It is important to note that for 2018 we computed
only 6 months:
R$143,998.40
R$38,222.60
R$145,079.00
R$836,339.20
R$255,248.50 R$265,471.80 R$321,282.20 R$327,030.00
R$961,750.20
R$0.00
R$200,000.00
R$400,000.00
R$600,000.00
R$800,000.00
R$1,000,000.00
R$1,200,000.00
Planalto Norte Foz do Rio
Itajaí
Serra Catarin. Vale do Itajaí Grande Fpolis Meio Oeste Sul Nordeste Grande Oeste
Max. Economy
Min. Economy
R$354,399.50
R$351,675.60
R$1,200,807.50
R$901,195.80
R$486,343.50
R$165,203.60 R$160,829.70
R$564,468.35
R$410,218.35
R$222,149.10
R$0.00
R$200,000.00
R$400,000.00
R$600,000.00
R$800,000.00
R$1,000,000.00
R$1,200,000.00
R$1,400,000.00
2014 2015 2016 2017 2018
Max. Economy
Min. Economy

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4.8 Impact on Resolubility and Referrals
Reducing healthcare costs goes hand-in-hand with Sustainable Telemedicine. So, first we wanto to present
a concept that is associated with the the case-resolving capacity in primary healthcare and is key in
implementing telemedicine in underdeveloped/under-served regions in a sustainable way:
Resolubility in Primary Healthcare: the capacity of a primary healthcare facility/family doctor/general
practitioner to solve the problem/healthcare condition brought by a given patient without referring the
patient to secondary/tertiary healthcare or a specialist.
In order to telemedicine be sustainable and systematically help to reduce costs, it has to enhance
resolubility at a primary healthcare level and not simply act as a faster way of performing patient
referral. This means that telemedicine has to be implemented in a way, employing processes and
protocols, that improves the problem-solution capacity of the endpoints of its network.
In this section we provide graphics of the consolidated referral and resolubility data showing the
percentage of avoided referrals and the resulting resolubility.
4.8.1 Impact on Referrals
Figure 10. Referred patients vs. avoided referrals per year
898
7,415 9,630
16,013
8,764
3,320
3,885
11,792
9,036
5,079
0
5,000
10,000
15,000
20,000
25,000
30,000
2014 2015 2016 2017 2018
Not referred
Referrals

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Figure 11. Referred patients vs. avoided referrals per Macro-Region
0
5,000
10,000
15,000
20,000
25,000
Planalto
Norte
Foz do
Rio Itajaí
Serra
Catarin.
Vale do
Itajaí
Grande
Fpolis
Meio
Oeste
Sul Nordeste Grande
Oeste
2018 Not referred
2017 Not referred
2016 Not referred
2015 Not referred
2014 Not referred
2018 Referrals
2017 Referrals
2016 Referrals
2015 Referrals
2014 Referrals

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Table 24. Referral data per Macro-Region. The last row consolidates the data per year
2014 2015 2016 2017 2018
Totals
Referrals
Not
referred
Referrals
Not
referred
Referrals
Not
referred
Referrals
Not
referred
Referrals
Not
referred
Referrals
Not
referred
Planalto Norte 41 73 255 176 353 505 477 234 183 130 1,309 1,118
Foz do Rio Itajaí
25
48
46
30
7
12
499
213
336
179
913
482
Serra Catarin. 202 394 380 150 113 300 584 284 415 203 1,694 1,331
Vale do Itajaí
229
680
2,447
1,303
2,462
3,290
4,195
2,786
2,143
1,317
11,476
9,376
Grande Fpolis 28 497 1,543 1,008 2,102 2,582 3,003 1,714 1,742 1,154 8,418 6,955
Meio Oeste
151
537
696
272
543
545
916
308
495
252
2,801
1,914
Sul 107 482 1,140 520 858 1,192 1,388 590 837 458 4,330 3,242
Nordeste
22
145
210
103
1,062
1,010
2,481
1,360
1,627
682
5,402
3,300
Grande Oeste 93 464 698 323 2,130 2,356 2,470 1,547 986 704 6,377 5,394
TOTAL
898
3,320
7,415
3,885
9,630
11,792
16,013
9,036
8,764
5,079
42,720
33,112
4.8.2 Impact on Resolubility
Teledermatology enhanced significatively the local dermatological case-solving capacity of the primary healthcare facilities.
Table 25. Consolidated resolubility data per year. Resolubility per year:
2014
2015
2016
2017
2018
Planalto Norte 64.04% 40.84% 58.86% 32.91% 49.34%
Foz do Rio Itajaí 65.75% 39.47% 63.16% 29.92% 33.58%
Serra Catarin. 66.11% 28.30% 72.64% 32.72% 44.03%
Vale do Itajaí 74.81% 34.75% 57.20% 39.91% 45.27%
Grande Fpolis 94.67% 39.51% 55.12% 36.34% 44.09%
Meio Oeste 78.05% 28.10% 50.09% 25.16% 42.36%
Sul 81.83% 31.33% 58.15% 29.83% 46.16%
Nordeste 86.83% 32.91% 48.75% 35.41% 31.60%
Grande Oeste 83.30% 31.64% 52.52% 38.51% 61.90%
TOTAL 78.71% 34.38% 55.05% 36.07% 44.24%

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Figure 12. Resolubility per year
Figure 13. Resolubility per MACRO-Region per year
78.71%
34.38%
55.05%
36.07%
44.24%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
2014 2015 2016 2017 2018
Resolubility
TOTAL
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
2014 2015 2016 2017 2018
Resolubility
Planalto Norte
Foz do Rio Itajaí
Serra Catarin.
Vale do Itajaí
Grande Fpolis
Meio Oeste
Sul
Nordeste
Grande Oeste

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5 Discussion
The large amount of low-complexity dermatology cases being unnecessarily referred to the reference
centers in Florianópolis made it clear to us that it was necessary to implement a triage system able to:
• Reduce the unnecessary referrals of simple, low complexity cases to the State’s dermatological and
oncological Reference Centers;
• Increase the case solving rates (resolubility rates) of the Primary Healthcare Facilities (UBS) at
upstate locations.
This challenge led us to develop and implement the Teledermatology model we employ at the STT/SC. This
specific study targeted the dertermination of the direct economical benefits of our dermatological patient
triage model. Teledermatological triage premisses, processes and protocols are discussed elsewhere.
International studies have demonstrated that the triage approach we follow has benefits over the
traditional primary care processes. There are, however, only a few studies analyzing cost savings generated
by such triage-oriented Teledermatology endeavors. Furthermore, no such study performed in Brazil could
be identified.
We understand that, besides showing that triage-oriented Teledermatology is effective from the point of
view of increasing the quality and case-resolution capacity of healthcare services offered, it is also
important for the Public Helathcare System (SUS) to be able to show that it is cost-effective and that it is a
sustainable solution that has the potential to be successfully implemented in other regions in Brazil and
also elsewhere.
The total patients processed in 2014 was 4,218, in 2015, 11,300, in 2016, 21,422 and in 2017 there were
25,049 patients. The large and continuously increasing number of patients that has been treated by this
service shows that the model is not only succsessful but also sustainable. This demonstrates that our
process was learned and integrated into the healthcare routine of a large number of UBSs in upstate
locations.
This integration into the working routine of the primary healthcare facilities is also visible on the rate of
invalid examinations and resolubility data:
• Invalid examination rates, which were very high at the beginning, have been continuously dropping,
as can be seen in Table 6 and on the graph depicted in Figure 6 on pg. 31. This shows that our
repeated continuous education efforts have been successful and are generating a “digital
examination” culture that has been internalized by the primary healthcare teams;
• Resolubility, as depicted in Figure 12 on pg. 60, from an initial value of almost 80% has dropped to a
value around 40%. This, at a first glance, can look bad, but it shows that people are learning
through Teledermatoloy and being able to solve various cases without submitting the patients to
the Teledermatology triage, not trying to send all cases for the review of a teledermatologist. What
at a first glance appears to be a decrease in resolubility, in fact means that the primary care
personnel is actually selecting better and the rate of Teledermatology cases that are probable
serious candidates for dermatological referral is increasing.

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Our interpretation of the reasons for the reduction of the resolubility after the first year of large-scale
operation of the Teledermatology service is reinforced by the fact that we can observe a slight heightening
of the resolubility in 2016 and 2018. Both periods follow an implementation effort of new teledermatology
points, as can be seen on the graphic in Figure 5 on pg. 29, and the temporarily heightened resolubility data
will probably reflect the activities, and insecurities, of new, teledermatology-unexperienced healthcare
professionals that entered the system. This is specially true for 2015, when we implemented the most
points.
5.1. Threats to Validity
In ordert o be able to offer the costs savings estimatives we presented in this work, we had to make several
assumptions and a few gross oversimplifications:
• In this work we assume that all patients seeking dermatological care would have been referred to a
specialist at a large centre and not treated locally if there wasn’t a Teledermatology service
available. Historically this really was the case and Brazilian primary care facilities tended to refer all
dermatological cases, independently on how simple and treatable they were. When we want to
compare our present Teledermatology scenario to a scenario where there does not exist
Teledermatology, we understand that the assumption of 100% referral is realistic.
• In this work we assume that all referrals would have been directed to a Tertiary Facility in
Florianópolis. This is mainly the case: most Healthcare Macro-Regions did not possess
dermatological attention resources at the public healthcare level and patients really would have
been referred to Florianópolis. In a few Macro-Regions (e.g. Itajaí Valley and Northeast) there were
dermatological and oncological facilities available and not all patients would have been referred to
Florianópolis. These Regions, however, are under the nearest to Florianópolis and distance does
not add much travel costs. We undertsand that this simplification is compensated by the fact that
far-located regions such as the Middle West and Greater West are large and not so well-served
with roads, and patients there would have come from many cities and from rural regions that are
much farther away than the main population centres we took as a mean distance reference for
each Region.

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