A survey carried out with 1,183 doctors in the states of São Paulo and Maranhão showed that the various uses of telemedicine – which emerged as an alternative during the health crisis caused by covid-19 – must remain in the Brazilian health system. The study, supported by Fapesp and the Newton Fund (United Kingdom), was conducted by researchers from USP, Federal University of Maranhão (UFMA) and Queen Mary University of London (United Kingdom).
“The multiple uses of telemedicine are here to stay. Technology has brought many advantages, but it is not a panacea. It needs to be regulated and monitored. For certain uses and specialties there may be a loss of quality with online. The non-face-to-face service often means low quality service.”
The statement was made by Mário César Scheffer, professor at the Department of Preventive Medicine at the USP School of Medicine (FMUSP) and the first author of the study.
Published in the journal Globalization and Health , the article is the result of a larger study , which analyzes the impact of economic crises on health and seeks solutions to improve policy management and the service provided to the population.
“Health systems, when adapting to crises – economic, political or health – end up finding solutions and alternatives that can be transitory or permanent. As our research project was in progress when the pandemic came, we decided, based on the study of the work of doctors, to understand changes in health that may have been accelerated by covid-19”, explains the researcher to Agência Fapesp.
The survey showed that telemedicine was most frequently used to connect professionals in the discussion of clinical cases (55%), in service meetings (48%) and in training and updating knowledge (40%). Less than a third of physicians reported having consulted and advised patients, a practice more commonly known as “teleconsultation”.
Telemedicine was used more by doctors working in the private sector than by professionals from the Unified Health System (SUS). Among professionals working in primary care, in outpatient and hospital services of the SUS, telemedicine was mostly used in services that treated patients with covid-19. “On the other hand, among doctors who work in offices and clinics, serving health and private plans, the use of telemedicine prevailed for care of health problems not related to covid-19”, he says.
The researcher explains that telemedicine is a broader concept than online consultations. Among its multiple uses are meetings with multidisciplinary teams for decision-making on treatments, training of health professionals, dissemination of new clinical protocols and teleconsultations.
“In this way, technology made it possible in the pandemic, for example, to take a specialist who was not available in that service or ICU at a given time to give an opinion and thus contribute to the proper diagnosis and treatment of patients”, he says.
Another important approach was the use of telemedicine for distance educational activities, such as courses, lectures and discussion forums. “In cases of health emergency, such as the pandemic, or even public health problems, it is also possible to use technology to standardize and disseminate clinical guidelines, therapeutic consensus, surveillance and public health guidelines, which are constantly evolving”, he says. Scheffer.
indiscriminate use
In the article, the researchers point out the potential risks of the indiscriminate use of telemedicine. “Further studies are needed, as our hypothesis is that, for certain health problems and certain specialties, telemedicine is not an effective form of care. It can be an aid, especially in screening and guidance, but there are situations in which the doctor-patient relationship in person is irreplaceable”, he says.
Other negative points of telemedicine commented by the authors are: possible failures in the notification of diseases, definition of physicians’ remuneration and ethical issues involving, for example, the security of sensitive data of patients treated online.
The researchers emphasize that much remains to be discussed. “The pandemic has accelerated the use of telemedicine and has also shown how much regulation needs to advance. We are concerned, for example, with the way in which telemedicine has been exploited by health plans and popular clinics to sell services at lower prices and worse quality”, he says.
Since March 19, 2020, two days after states decreed quarantine and the closure of services and commerce because of the covid-19 pandemic, the Federal Council of Medicine (CFM) and the Federal Senate released telemedicine for a provisional period. More recently, in May 2022, the CFM definitively regulated the practice. Despite the release, the council stressed the importance of face-to-face consultation.
inequalities
The work on telemedicine is based on a survey of 1,183 physicians – a representative sample of the 152,511 professionals active in the two Brazilian states. São Paulo and Maranhão are quite heterogeneous, both in terms of the density of physicians and in terms of the size of the health system and socioeconomic indicators.
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“The survey results also show inequalities in the use of telemedicine and this is a wake-up call. We observed that technology was used much more in the private sector than in the public sector, in the capital than in the interior and in São Paulo than in Maranhão”, lists the author.
The study pointed out another important aspect of the unequal use of telemedicine: the fact that, during the pandemic, online consultations were much more related to non-covid-19 care. “During a health emergency, a pandemic, there are patients with other health problems who need to continue to be cared for. The teleconsultation was activated to keep the services and offices running, even if it was not ideal”, he says.