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ADOLESCENT MEDICINE (M GOLDSTEIN, SECTION EDITOR)
Telemedicine: a Bridge Over Knowledge Gaps in Healthcare
Evelyn Eisenstein
1,2
&Cristiane Kopacek
2,3
&Suzy Santana Cavalcante
2,4,5
&Almir C. Neves
2,6
&Gustavo P. Fraga
2,7
&
Luiz Ary Messina
2
#Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract
Purpose of the Review The purpose of the review is to describe the Brazilian Telemedicine University Network RUTE
concerning the Special Interest Group of Children and Adolescents, the new SIG-COVID19-BR activities for continuing medical
education, and to update relevant information regarding diagnosis and treatment, using digital technologies.
Recent Findings A total of 145 sessions of video and webconferences were held with the participation of 6575 health professionals,
including medical students, interns, and residents. Major topics involved the healthcare of children and adolescents were combined with
the emergence of a new pandemic plus the need to decrease the professional knowledge gaps in geographically distant hospitals.
Summary Telemedicine is a cost-effective tool and a bridgeto decrease health disparities access for proper care and assistance for
any population. RUTE is a Brazilian model of telemedicine which has a positive impact attracting the participation of health
professionals, and even more so, during the Covid-19 virus pandemic outbreak.
Keywords Telemedicine .Pediatric healthcare .Distance learning .Medical training .Videocollaboration .Webconferences
Introduction
The discovery of new space possibilities, to reach out for new
horizons and to fight against diseases has been medical and sci-
entific challenges for many centuries. Recently, there has been an
increased leverage via the use of rapid image and voice technol-
ogies, including the internet and digital communication.
Telemedicine is one of these innovative tools to help con-
nect health professionals, different medical practices, and spe-
cializations, including pediatric healthcare all over the world.
Beginning in2006, Brazil began toaddress the obstacles, with
the development of the Brazilian University Telemedicine
Network (Rede Universitaria de Telemedicina,RUTE)
linking federal and state university hospitals and medical
schools [1•]. The Special Interest Group (SIG) of Children
and Adolescent Medicine and Health was the second SIG
created during 2008 with partnership and collaboration be-
tween pediatricians from the Federal University of Bahia
(UFBA) and the State University of Rio de Janeiro (UERJ).
This major decision was one of the foundations of a new
telemedicine bridge that has been constructed and empowers
as many as 61,033 health professionals, including residents
and medical students, since then. RUTE is a collaborative
network nationwide which started to register participation di-
rectly online, after 2015. The organization, planning, and im-
plementation of 6508 video and webconferences have been
shared between Brazilian universities and international guest
speakers, with two to three daily activities that also occur with
55 other SIGs of different areas of interest [1•].
In the beginning of 2020, the challenges raised by the Covid-19
pandemic were another reason for the development and structure
of a new SIG called COVID-19-BR. Since March 23, 2020, there
have been 23 national and international webconferences and state-
This article is part of the Topical Collection on Adolescent Medicine
*Evelyn Eisenstein
evelynbrasil@hotmail.com
1
University of the State of Rio de Janeiro (UERJ), Rio de
Janeiro, Brazil
2
RUTE, Brazilian University Telemedicine Network, Rio de
Janeiro, Brazil
3
Federal University of Health Sciences of Porto Alegre (UFCSPA),
Porto Alegre, Brazil
4
Department of Pediatrics, Federal University of Bahia (UFBA),
Salvador, Brazil
5
TeleHealth (NUTS), Salvador, Brazil
6
Department of Women, Child and Adolescent Health, Federal
University of Ceará (UFC), Fortaleza, Brazil
7
School of Medical Sciences, University of Campinas (UNICAMP),
Campinas, Brazil
Current Pediatrics Reports
https://doi.org/10.1007/s40124-020-00221-w
of-the-art professional exchanges on diagnosis, care, and treatment
options, including networking with medical professionals from
Israel, Italy, Portugal, Spain, Switzerland, and USA. RUTE has
also pioneered professional and health liaisons with many Latin
American/RedCLARA and Portuguese speaking countries, as part
of CPLP/Comunidade de Países da Lingua Portuguesa/
Community of Portuguese Language Countries [2,3]. More by-
side telemedicine bridges and network opportunities have been
constructed along with other medical and health professions mem-
bers of Healthcare Information for All in Portuguese/HIFA-pt and
Children’s Healthcare Information for All/CHIFA [4].
Definition and Background
Telemedicine has been defined as the use of telecommunication
and information technologies to support the delivery of
healthcare at a distance. Telehealth has a broader definition,
encompassing telemedicine’s clinical care and tele-education
for research, disaster planning, and primary healthcare at geo-
graphically distant and poorer areas. Telemedicine and telehealth
are commonly used today and are considered synonymous or
complementarytoeachother[5,6•]. The World Health
Assembly WHA71.7, Agenda item 12.4 on May 26, 2018,
recalling resolutions WHA58.28 (2005) on eHealth, and
WHA66.24 (2013) on eHealth standardization and interoperabil-
ity, emphasized the benefits, opportunities, and challenges for
countries, considering an even broader area as digital health [7•].
Telemedicine involves, not only sharing of information be-
tween experts, but also distance education and efficient collabo-
ration with decision-making in real-time, including
videocollaborations, audiovisual tools, and exchange of docu-
ments and up-to-date protocols. It enables people who cannot
be physically present to start a respectful conversation or discus-
sion of difficult clinical case or themes to overcome obstacles in
diagnostic or treatment procedures. It also allows the sharing of
files and data so that it is easier and faster to reach out or review
documents to make universal health coverage achievable.
Concerns about ethics, data confidentiality, informed consent,
confidence, and medical security are always essential compo-
nents of this bridge construction, ensuring transparency is a part
of this technological digital strategy option [7•,8].
Brazil has an estimated population of 204 million people,
of which 34% are children and adolescents corresponding to
65 million individuals between 0 to 19 years of age, with
social, educational, and health disparities and inequalities.
Even so, all are considered subjects with their own rights with
social protection assured by the Family and the State, with
absolute priority by the Federal Constitution (1988) article
no. 227, based with the United Nations Convention of the
Rights of the Child (UN-CRC) [9]. There is a free public
health system throughout the country with medical assistance
and health services available in each municipality, Sistema
Único de Saúde (SUS) under the responsibility of the
Ministry of Health [10].
Due to its large land mass of 8514.877 km
2
, Brazil is di-
vided into 5 major regions and 27 states. Eighty-three percent
of people live within urban areas and some 17%, which cor-
responds to 33 million people, live in rural, including indige-
nous remote areas, mainly in the North, Northeast, and Central
regions (Amazonas, Pará, Amapá, Acre, Roraima, Rondonia,
Mato Grosso, Maranhão, Piaui). The education of health pro-
fessionals across such large and diverse areas is a difficult
task. That said, Portuguese is the common language, and the
internet is crucial, for communication and information
throughout the country.
Brazil has established a safe and innovative space for the
discussion of strategic issues related to the development of the
internet and its governance in the country. Throughout its devel-
opment, the Brazilian Internet Steering Committee (CGI.br)
played an important role for the global debate on internet gover-
nance with the goals to support the formulation, implementation,
and evaluation of public policies to foster the use of Information
and Communication Technologies (ICT). Its main goal is to
improve the internet and to contribute to digital inclusion, with
more open and transparent debates and planning of public poli-
cies. The major federal and state public universities are connected
through the Telemedicine University Network RUTE [1•]with
the Ministry of Science and Technology and National Research
and Education Network NREN (Rede Nacional de Ensino e
Pesquisa RNP) support. RNP connects all public and private
research and education (R&E) institutions nationally, but regard-
ing health R&E institutions, its main objective is to connect the
several university and teaching hospitals in the country into a
single information network under the umbrella of RUTE.
Currently, there are 139 Brazilian universities connected
within the RUTE network with 27 (20%) located at distant
points in the country. One example is the Amazon north region
is the teleassistance for the so-called basic health unit in 62
municipalities that are connected with the specialists from the
Federal University of Amazonas (UFAM) for second opinions
using RUTE technology. There are 55 different groups of spe-
cialization called SIGs, dedicated to specific health areas, e.g.,
cardiology, dermatology, human milk bank, indigenous health,
medical education, data science and artificial intelligence (AI),
children and adolescent health, and pediatric endocrinology
among many others. Once certified, participating institutions
are free to propose, create, and coordinate special interest
groups (SIGs) among their professional expertise, covering
medical and health topics, all operating under RUTE’sinfra-
structure and technical support (see Fig. 1).
Telemedicine has been relevant for the continuing educa-
tion of medical and health multiprofessional residents. RUTE
ran in 2015, 2016, and 2017, a nationwide update course for
residency preceptors which involved hospitals in all 27
Brazilian states. There were on average 45 videoconference
Curr Pediatr Rep
rooms and 617 health professionals every week during
12 weeks and 2-h session/week, having more than 7000 par-
ticipants and a cost avoidance of circa 4 Million US$ [1•].
Telemedicine can be a useful tool for the training of teams
and, for this main reason, it is becoming more frequently used
in several areas of capacity building and medical trainings. It
was adopted for the preparation of hospitals for disasters and
catastrophes before the FIFA World Cup, in 2014, and the
Summer Olympics, in 2016 [11]. A study showed a disaster
preparedness course via telemedicine was one of the solutions
to overcome the logistical and cost obstacles involved in the
rapid and decentralized training of teams with gain in knowl-
edge by participants in a distance-learning course [11].
Pediatric Healthcare
Since 2008, there have been 122 videoconferences implemented
by the 47 medical institutions and teaching hospitals with pedi-
atric services which integrate the SIG for Children and
Adolescent Medicine and Health. At the present time, we also
have the support of the Brazilian Pediatric Society/Sociedade
Brasileira de Pediatria with some telemedicine sessions and
other special debates which have resulted in scientific documents
then disseminated through the society’swebsite[12].
Videoconferencing occurs once or twice a month, for
1 h with half hour for a question and answer period. It
is always very interactive with lively discussion, includ-
ing residents, interns, and medical students in addition
to the staff or the guest speaker and the moderator. It is
structured with a very holistic and humanistic approach
covering the interdisciplinary aspects of the theme or
the clinical case presented and discussed also by the
team’s psychologist, social services, or invited physio-
therapists, accordingly. There is a rotation between the
institutions depending on the demands or updates. All
videoconferences are saved on the RUTE public digital
video library and databank and are freely available for
consultation, thereafter [1].
During the past 12 years, discussion of complex medical
cases with consultation to obtain second opinions was com-
pleted through international videoconferences, which had a
positive impact. A few of our (SIG-RUTE) collaborators are
from Center on Media and Child Health/CMCH at Children’s
Hospital in Boston, MA; Medical Missions for Children/
MMC at Children’s Hospital in Patterson, NJ; The Johns
Hopkins Hospital and Medical Institutions in Baltimore,
MD; Georgetown University Hospital in Washington, DC;
and Children’s Hospital in Sydney, Australia.
Videoconferences also have been held with the Pan
American Health Organization in Washington, DC, and with
the World Health Organization in Geneva [13].
Some public health education campaigns were
launched, simultaneously through a telemedicine session
with the Children’s Hospital in Sydney, Australia, includ-
ing the shaken baby syndrome, with the translated video
saved at a YouTube platform and having more than
82,000 views, since 2009 [14]. This theme of abusive
head trauma was afterward recognized as a priority for
another initiative on violence prevention and a scientific
literature review was published [15]. Another educational
video on violence and abuse prevention with interventions
was produced with support from the International Society
for Prevention of Child Abuse and Neglect (ISPCAN). It
became part of the content for an online course through
the TeleHealth Service (UERJ). During the period of
5years,morethan7000healthprofessionalscompleted
the 10 modules with 60-min webconference sessions and
evaluation of field cases presented by the participants af-
ter completion of a 10-h e-education practical course [16].
Major telemedicine sessions and topics of the video/
webconferences implemented which had greater impact in
respect to participation can be categorized as follows:
Fig. 1 Maps of the Brazilian universities and medical institutions that are members of the SIG for Children and Adolescent Health and Medicine and the
SIG COVID-19-BR of the Brazilian University Telemedicine Network, SIG-RUTE-BRAZIL-2020
Curr Pediatr Rep
&Epidemic outbreaks: dengue fever, zika, chikungunya,
yellow fever, measles, and other viral infections, like
H1N1 and the recent coronavirus (Covid-19);
&Early diagnosis of developmental disorders: autism spec-
trum disorder, Asperger’s syndrome, speech delay, cere-
bral palsy, and inborn errors of metabolism;
&Health rights and ethics: social violence, sexual abuse,
adoption, drugs, and alcohol;
&Nutritional and eating disorders: anorexia, bulimia, over-
weight, obesity, and anemias;
&Endocrine disturbances affecting children and adoles-
cents: congenital and acquired thyroid and adrenal dis-
eases, disorders of sex development, diabetes, growth
and puberty disorders, and endocrine tumors;
&Breast feeding health campaigns and protocols;
&Teenage pregnancy and sexually transmitted infections/
HIV, HPV, HepC;
&Immunizations and yearly vaccination calendar, public
health campaigns;
&Traumatic care, accidents, burns, drowning, and preven-
tive measures;
&Mental health and behavioral problems: school dropouts,
suicide, attention deficit disorder and hyperactivity, and
family therapy;
&Indigenous health and major respiratory outbreaks;
&Digital health: gaming, privacy and safety online, and
hazardous games
Covid-19
During January 2020, a cluster of cases of pneumonia and
respiratory diseases was reported in China, and on January
22, the World Health Organization (WHO) issued the first
statement that there was evidence of a new coronavirus with
human-to-human transmission [17]. International news
sounded an alert on February 3, when WHO released a docu-
ment with the strategic preparedness and response plan to help
protect states with weaker health systems outlining the public
health measures that the international community stands ready
to provide support in case of such epidemic emergency, in-
cluding the use of telemedicine [18•]. On March 11, due to the
alarming levels of spread, severity, and high transmissibility
with increase of death rate tolls, WHO declared the new virus
outbreak as a pandemic. The first Brazilian death from Covid-
19 occurred in São Paulo, on March 17, 2020.
RUTE’s national coordination team organized one extra na-
tional advisory scientific planning committee meeting in
March 20, 2020. The SIG COVID-19-BR was launched that
day, as an emergency initiative between the leadership of the
University of Campinas (UNICAMP), State University of Rio
de Janeiro (UERJ), and Federal University of Health Sciences of
Porto Alegre (UFCSPA). The first videoconference was held on
March 23, with the participation of all RUTE’shealthprofes-
sionals for collective planning of the several institutional de-
mands, resource needs, and knowledge gaps for information on
diagnosis and treatment of the new viral disease Covid-19.
The SIG COVID-19-BR professional network meets three
times a week, during lunch break for 1 h, for national and inter-
national webconferences to facilitate the transmission of video
materials and all medical protocols with the possibility of a chat
with questions and answers for the final debate period. All pre-
sentations are recorded with prior permission and saved for future
public consultations at RUTE’s special Wiki website [19•].
So far, there have been 23 presentations through
webconferencing and streaming with invited guest speakers
from Israel, Italy, Spain, Portugal, and USA sharing their ex-
pertises and difficulties on diagnostic tests and exams. There
have been large debates with participation of medical profes-
sionals from 22 different Brazilian states out of 27, including
an average of 100 participants for each session, while a shared
session between SIG COVID-19-BR and SIG Pediatrics
Endocrinology on May 11 registered 181 participants.
It is also important to highlight the participation of medical
students, interns, and residents during the SIG COVID-19-
BR. Medical and nursing students, assisted by their profes-
sors, presented their orientation work as they are helping with
prevention actions and informing the general public with the
program called ORIENTA+Covid-19, created at UNICAMP.
So far, they have attended to more than 1000 telephone calls
from the population searching for Covid-19 safe recommen-
dations. This model regarding students trained by professors
to give recommendations to the population is also creating a
new SIG to stimulate and disseminate the model to other uni-
versities in Brazil. Some already have such a similar proce-
dure, enabling the start of a national health student network,
professor oriented, and student focused on health prevention
for the population, enhancing their professional education on
primary healthcare.
Another special initiative was held with the partnership of
RUTE and RNPI (Rede Nacional pela Primeira Infancia)
National Network for Childhood, with a webconference on the
mental health secondary repercussions within the families with
children at home during the quarantine period. This was an open
and public national session directed to parents, journalists, and
educators from 12 different states and demonstrated that RUTE’s
professional network can also have a positive impact for the
general public as a health education dissemination tool [1•].
Discussion
Science is the search for the unknown and medical science is
the search for diagnosis, treatment, and healthcare for any
disease and other morbidities affecting anyone anywhere in
the world. Telemedicine has been a virtual electronic bridge
Curr Pediatr Rep
between medical specialists at the teaching hospital and the
remote attending physicians, who can be geographically dis-
tant, but share their knowledge and practical expertises at the
same time, talking and seeing each other on the other side of
the computer screen, in a digital room. The challenges are not
only immediate communication with efficient technical sup-
port, but also the outreach for a diagnosis and sharing any
protocols to decrease the knowledge gap between medical
colleagues as partners, even at distantly related community
hospitals or basic health units, in different areas of the country.
It is also an opportunity to establish a deeper connection to-
ward human and health rights, to give and to receive the best
possible answer for care, cure, or control of a specific disease,
with the priority for children and adolescents, including the
use of secure digital environment [11,20•].
The importance of capacity building and professional or aca-
demic medical training and positive continuing medical educa-
tion toward some more complex diagnosis has also played a
secondary but integrated role for the video and webconferences.
These sessions are recorded and broadcast or reviewed, anytime
with open access by other physicians or medical students or they
are used as a forum for global learning.
The professional networkand experiencedeveloped during
the past 12 years with the SIG Children and Adolescents
Health and Medicine and other SIGs with the technical sup-
port of RUTE was a significant step to the rapid response to
the Covid-19 challenge. Telemedicine provided the right tool
for the initiative to enhance medical information break-
throughs to distant university hospitals in Brazil.
The emergence of the pandemic also raised some legal and
regulatory aspects about rules and criteria for appropriate
teleconsultation between health professionals who are hospital-
based or privately based. The Federal Council of Medicine had
released a resolution CFM 1643/2002 defining telemedicine as
the practice of medicine through the use of audiovisual interac-
tive methodologies with communication of data for the objec-
tives of medical assistance, education, and health research. Only
recently, a new resolution has been approved for the exercise of
telemedicine for all Brazilian states [21]. As Brazil is now con-
sidered to be in a state-of-emergency due to the Covid-19, a new
telemedicine law has been approved recently by the Ministry of
Health enabling the so-called teleconsultation direct between lo-
cal physicians taking care of a hospitalized or ambulatory patient
with a remote specialist through the digital screen, which had not
been permitted before [22].
To practice medicine is a professional commitment to share
knowledge with a team in any hospital and also to keep up-
dated with scientific, practical content. Telemedicine offers a
perfect tool for this exercise. The university and teaching hos-
pitals are always a place for knowledge mentorship, renewal,
and prestige, especially when allocating available time
for networking with other professionals around the
country or internationally.
It is also important to focus on the positive educational
impact for medical students, interns, residents, staff, and mul-
tidisciplinary teams. These groups learn and share concerns
during the lively and respectful interaction and question and
answer period following the main presentation of the telemed-
icine topic chosen at that session.
Conclusions
Telemedicine represents an important tool for the education of
medical professionals and the distance learning to provide
medical diagnosis and treatment, direct and indirectly with
outreach and screening programs, especially for children and
adolescents in poorer areas in Brazil. It has been also a more
effective collaborative researchtool creating a digital space for
interaction, teleassistance to the health professionals, and also
teleconsultation direct to the patient, beside image diagnosis
and second opinion.
To facilitate the transfer of medical knowledge from its
source in research centers, by the use of audiovisual and dig-
ital equipment, is a way to decrease the information gaps for
healthcare providers at underserved hospitals. It is more than a
technological or communication challenge; it is a bridge con-
structed over troubled water [23].
The professional commitment of healthcare workers is an
example of a vital task that can be eased by the use of tele-
medicine. This is a cost-effective method available for any
hospital or even during any emergency, like a disaster, by
overcoming personal or technological barriers.
The insertion of ICTs for the consolidation of digital health,
telemedicine, and telehealth is inevitable, demonstrating the
guarantee of the effective and efficient application of health
services to the entire population, finally allowing governance
based on scientific, reliable, safe, certified, and governed in-
formation under the general data protection law.
Much has been accomplished so far through telemed-
icine to implement healthcare for children and adoles-
cents in Brazil. The Covid-19 pandemic has allowed
some processes to accelerate, expanding telemedicine’s
sphere of action in both education and assistance.
Brazilian universities, with the support of RUTE, have
applied their range of performance, bringing a clear
benefit to improving healthcare for the entire popula-
tion. The way is open for many present and future ini-
tiatives, in which telemedicine will certainly be the dif-
ferential, here and worldwide.
Acknowledgments Thiago Lima Verde, Luan Meirelles, Max Moraes
(RUTE); Mario João Jr. (UERJ); Jeferson Batista dos Santos, Thiago
Santana Dias, Samuel Lima de Farias, Bruno da Silva Santos (NUTS,
UFBA); Antonio Carlos da Silva (UNICAMP) for their technical support;
Frank and Peggy Brady from Medical Missions for Children; Pierre
Rodriguez from Poly; John P Howard for revision.
Curr Pediatr Rep
Compliance With Ethical Standards
Conflict of Interest The authors declare no conflict of interest.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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Papers of particular interest, published recently, have been
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Available at: https://www.youtube.com/watch?v=4G-YQA_bsOU.
Publisher’sNoteSpringer Nature remains neutral with regard to jurisdic-
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