Telehealth in the

Telehealth in the

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Edited by Richard Wootton, Nivritti G Patil, Richard EScott and Kendall Ho

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© 2009 Royal Society of Medicine Press Lld

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Co-published by Royal Society of Medicine Press Ltd 1 Wimpole Street. London WIO OAE, UK Tel: +44 (0)2072902921 Fax: +44 (0)20 7290 2929 Email: [email protected] Website: www.rsmpress.co.uk

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Telehealth in the Developing World

Edited by

Riehard Wootton Scottish Centre for Telehealth, Aberdeen, UK; University of Queensland, Brisbane, Australia

Nivritti G Patil Universíty of Hong Kong, Hong Kong, China

Riehard E Seott University of Calgary, Calgary, Canada

Kendall Ho Jníversíty of British Columbia, Vancouver, Canada

Tile

ROYAL

SOCIETY of

lnternational Development Research Centre :-::".',a· Cairo' Dakar' Montevideo' Nairobi' New Delhi' Singapore

MEDICINE PRESS

[,miteJ

Informatio~~

technology for

I-n pr'"lmai"UJ ~.a~~tlliii~~iii.n ;=t.are " razii li

li

Elaine Tomasi, Luiz A Facchinl, Elaine Thumé, filiaria FS Maia anel Alessancler usaria

Inlroduction Decision in public health depends 011 the of reliable information. which 18 analyzed and disseminated by informadon systems. L2 However. most national health infoffi1ation systems lack r.he information needed to address health namely. reliable, longitudinal data that iínks rneasures ofhealth with rneasures of social status at the individual or small-area leveI. for promoting greater in management processes. studies evaluatíug the impaet of sueh ou heaith are still rare,5.6 most authors agree that tnere are positive effeets: f!'Orn these systems and lhat they ean be improved further through health care are very common. Further­ Low leveIs of computerization in more, many papers stress the need for contínued motívation and training for all team members as a prerequisite for the success of any initiative in this area. 78 lt may be n~rt""""T here to quote the reflections by Branco 9 on the significance of trainiog, that the ampIíficatíon of knowledge: of the logic behind health information production and flux must be to ali persons involved, and should include an understa,"'1ding of the of the systems to which they have access, and of the possibiiities for use of the info1111ation produced ... ?\1artinez et apo analyzed communication and ínfonnation needs in care in rural areas from Peru alId found three main factors related poor infrastmcture, a lack of information the inefficiency of the health of health professionals. Other authors ha\(' systems and defieieneies in the emphasized the need to incorporate good-quality health care data from local level~ into national databases.ll~14 Simílarly, Gething et aJl5 stated that the value

34

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2:: c o,,:h'iology for primary heaith care in Brazil

informatíon systems in health is to point out the Ilêed, and priorities at both national and local leveIs, but the process of feeding data into the systems often fails. Another source of problems is the contrast bet\veen the availability of information technology (lT) at the central leveI of health system management and it5 shortage e15ewhere, particularly in primary care. There is often pressure for new data, increas­ the time required for collection, wíth no assurance about its analysis, disserrúna­ tion and usefulness in decision making. The great quantity of data about each palient, recorded by health professionals, seems to have little meaning in their daily actívi­ ties. 16 We believe that alI of these factors contribute to the current situation but especially the lack of motivation of 1110s1 health care staff and the poor integration between health care and IT professionals. Establishing IT in the health services, especially in primary care, is a challenge for the advance of information systems, not on!y in the smaller and poorer towns. In bígger cities, the central leveIs of the health system generally have good access to IT resources, but the recording of the actions of the major part of the health services is ,til! performed manual!y.16 There are few reports in the líterature about the experience with the deveIopment Jnd use of computerized systems in primal'Y care. Hennan et alI' described the Com­ munity Health Information Tracking System (CHITS) in the Philippines, which has the objective of integrating loeal and national leveI information and pointing out 'islands' in the information systems and a great amount ofrepeated work in the man­ agement of such systems (see also Chapter 3). Aspects related to access to data from Jifferent information systems. and their use and contraI, should be considered, inc1ud­ ing their creation, implementation, monitoring and evaluation. 18

IT in primary care in Brazil Two recent initiatives from the Brazilian govemment are the National Information Policy on Informatics in Health (NIPIHlPNIIS)19 and the National Telemedicine Pro­ Eramme in 2006. 20 The NIPIH focuses on health work, on the user and on the elec­ ,ronic health recordo The proposals are underpinned by standards to represent and "hare health infonnation, the connectivity structure, the training of human resources the information systems in health, and, above ali, the guarantee of privacy and con­ :1dentiality of the information.

National Telemedícine Programme Telemedicine activity currently involves about 30 universities and research institutes 9 of the 27 Brazilian states. The pilot project in telemedicine for primary care I1\'olves the installation of 900 PCs, mainly for decision support. These PCs are con­ =-ected to a wide area network, and can also be used for videoconferencing. They have :.,., electronic medicaI record, which can be shared with other units. Priority is being to CÍties where there i5 a family health programme, a population 01' less than 'O 000 and geographical barriers to health care. The Ministr)' 01' Health, together

35

Telehealth In the Deveíoping Worid

with the Ministry of Education, has been investing in distance learníng for training and continuing education of health professionais.

National informatíon systems 'lhe information systems available in Brazil consist of large databases of statistics. These include hirths, deaths and a disease surveillance system. There are also tools for the management of outpatient and hospital services. The only computerized health information system used in family heaIth centres is the Primar)' Care Information System. This is the source of information, and provides most of the tools and the fonus completed by the primary care team. Mos! health pro­ fessionals recognize it as a tOOl for improving the epidemiological profile, but it is underutilízed. According to the staff concerned, this underutilization is due to various lill1itations of the system, to a lack of knowledge and lack of preparatíon for exploring its fuH capacity, to a lack of training and to a lack of incentive to use it for data analy­ siso The system has weak:nesses, but some professionais also have difficulties in it both regarding the input of data and in producing reports. Data collection is fragmented, with no connecrion with heaith polieies to facilitate the planning and decision ll1aking. The data collection and transfer mechanisms generate repeated work and reduce efficiency in the management of infonnation. The system does not allow integration with otner and cannat identify users and show their links to health services. For Lhis, a National Health Card i5 being implemented. However, because of the magnitude 01' the investment requircd, progress has been slow. The prolíferation 01' information systems should be highlighted. For cach need, sector, disease or event, new software is created, implying high costs for development and ll1aintenance, and a lack of standardizauon and interoperability. According to Cohn et aI, 11 there is little use of informatien frem the large databases in Brazil, espe­ cially in smal! towns. The fül] potential of the information has yet to be realized. 12.21

TeJemedícin e from the National Telemedicine Programme, the BH Telemedicine Project was ímplemented in 2003. Tne aim was to promote t1e continuing education of health warkers in primary care units, as well as contributing to the modemization of the public health system. The BH Telerl1edicine network connects prinlarf care centres to the Federal University of Minas Gerais teaching with activities in the fields of medicine, nursing and dentistry. The network uses videoconferences for contínuing educatioo, and teleconsulting between and staff at the prill1ary care centres for secol1d opil1ions al1d for discussion of clinicaI cases. The videoconferencing network operates at 128 kbit/s. The telemedicine network has been implemented in 121 primary care centres. About 1500 teleconsultations per year OCCill between a"d 5taff at L'1e priInary care centres. In 2006, there were 75 educational videoconferences, including medicaI, nursing and dentistry areas, involving more than 5000 participants. The activities have resulted in more effective pmticipation of the oral health group, fo1­ lowed nUl'ses and finally by the physicians. ",;;:;vatal"

36

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The project has been evaluated by two groups. The results showed better outeomes for the cases discussed, wirh about 70% of patients staying in basic units. with no neecl for refeITal to a specialíst. There was also a recluction of 71 % in the number of patients who needecl to traveI to the Clinics Hospital of Belo Horizonte to be seen.

Computerízed tools In 2005, a survey was conducted to characterize primary care and evaluate clifferences in the effectiveness of services accoreling to the model of care heaIth or tra­ ditíonal. 16 Under the Family Health PrograilliTreS (FHP). teams are composed of a doctor, a nurse, a nurse technician and about tive community hea!th agents. These teams are responsible for a set number of families (about 1000) Jiving in a particular area. The teams undertake work illVolving health promotion, prevention. recovery and rehabilitation, In the traditional model, teams do not include community health agents anel do not have their activities focuseel on health promotion and disease prevention. The survey enrolled 41 municipalities of more than 100000 inhabitants in the south anel norL~-east regions of which representeel 20% af these size municipalities in the country. There were systematic differences between the demo­ graphic and socioeconornic indicators from the south and north-east of the country. In the south, the average human development index (li])!), life expectancy, number of 1iterate people anel homes wilh tap water supply were higher than in the north-east. ~orth-east rnunicipalities showed a higher proportion of poor peopie (41 % vs 17%), while the southern rnunicipalities showed a higher proportion of citizens (9% vs 7%). Information about the 236 primary caIe centres was obtained by questionnaire: -1-749 health workers were stuelieel. Among these, 11 % were physicians. 7% nurses. 8% professionals with another college degree, 18% nursing assistants. 23% otheI pro­ ressionals with a school anel 33% cornmunity health agents. One-thirel of lhe primary care centres hael a computer (3590): 40% in the sout:h and 29% in the north-east. the care model, 39% of the family health services hael a com­ puter, as opposed to only 25% of the traditional services 4.1). OnIy 11 % of the primary care centres had Internet access: 17% in the south anel 5% in the north­ east region. The traditional services had more Internet access (14%) than the family health services 4.2). About 20% of lhe health workers mentioned their use of eomputers for professional activities. This use was almost 50% among physicians, nurses and other professionals with a college anel a little more than 10% among technicians, com­ munity health and other members of the teams wIlo had a high school educa­ tion. The use of computers in the primary care centres was even less rrequent, being mentioned only by 8% of the professionals (Table 4.3). Depending upon the region, the use or computers in health centres was 14% in the south anel 5% in the north-east. Depeneling upon the care model, it was 10% in family health services fu,cl6% in the traditional centres 4.4).

37

Telehea!ih in lhe Deve!oping World

Tab!e 4.1 Microcompulers in primary care services according io lhe mode! oí healih care and geographical region (n = 236) South (%)

North-east

Total

(0/0)

("/o)

39

Family heailh

46

33

Tradilional

30

16

25

Totai

40

29

35

Tabie 4.2 Access to the Internet in primari caíe services according to the model of hea!th care anti

geographica! region (n = 236)

Sou!h (D/o)

North-east

Total

(%.)

(o/c)

~

Totai (%)

Family healih

15

6

10

Traditiona!

12

3

6

Tetal

14

5

5

PACOTP-,pS is a tool for decision making. The objective oftne PACOTAPS software is to assist health managers and teams with information about population characteris­ tics and health demands. 22 The software provides a structure to receive data about the contacts and procedures pelf01Tned at primary care centres. The origin docüment is

38

!r:ioc"'a:~~,

:&Crnology for primary health care in Braz!;

the Outpatient Contact Fonn, whích is completed the health team and signed by the user. Once the form has been completed, the data are typed in using a module called users contact wirll the services. PACOTAPS íncludes lists of professionals, groups and procedures that are stand­ ardized by the Outpatient Information System. For the identification of the diagnosis, PACOTAPS provides the application PESQCID,23 which allows a guided consultancy to the International Classification Df Diseases (lCD- IO). Thus, using the system ít is possible to find out, for a certain period of time, the distribution of patients by age and gender, the main diagnosis and the proportion of refen·als.

Traíning About 400 primary care workers from the 41 cíties under study were trained in moni­ wring and evaluation through practice exercises in a computer laboratory, in two regional workshops. The participants could install, become familiar with and use PACOTAPS, wíth emphasis on the module users contact wíth the selTices. Thus. they \Vere able to understand its usefulness for the daily activities of plimary care centres, and in municipal health management. The simplified data entry and the immediate lvailability of reports were very attractíve, as these are requirements often mentioned by hea1th workers. The training aims to make health workers aware of the need to produce accurate and valid infonnation. At the end of training, each municipality received a CD for installation of the software and the application manual.

Survey re.:-:.i/ts In the PROESF study, all the 26 019 user contacts with the primary care centres were recorded in PACOTAPS. Infonnation was collecteel about the users' profiles (age, gender and health problems), the procedures performed and the refenals. One-third of the contacts (35%) were for women between 15 and 49 years old, i.e. of reproductive age. The second largest group was for people 60 years of age or oIder (l9%) anel the third largest group was cbildren below 5 years old Every user can receive one or more procedures at each contact. For example, a child may receive an immunization and a150 have a medicaI consultatíon for díanhoea; an dderly person may have bis or her blood pressure checked, have a medicai consulta­ LÍon for back pain and receive his 01' her medication; a pregnant woman may have her weight checked, have a medicaI consultation for urinary infection anel be attended to the social worker for receiving a benefit. Therefore, the number of procedures is usually higher than the number of people attended to. In this sample, more than 37 000 procedures were analysed. Although nurses and nurses' assístants comprised 25 % of the teams, they performed more than half of the proeedures (53%). The physícíans, who represented 11 % of the professionals, accounted for 26% of the procedures. Almost 70% of the proceelures \\ere related to factors that inftuenced the health status and the contact with L.'1e serv­ .ces, such as prenatal care and paediatrics, immunization and screening tests. After 'bis, health problems relateel to the digestíve system circulatory system (4%) :md respiratory system (4%) were observed more frequently.

39

Telehealth In the Deveioplng World

Although 23% of the records did not have ínformation about ít was observed that in 70% of the contacls there was no need to refer the user to other care leveIs ar to request diagnostic tests.

Conclusions Primary care plays a major role in producing better health care for all people, n»rtll'!l_ larly in developing countries. Efforts are now being directed towards the improve­ ment of dífferent madels of care. As in other places, in Brazil, fatl1íly health care ís becomlng a successful equity promotion effort, because it 1S morc widely present in poorer with a more vulnerable popuJation. Despite limitations that are common to primary care, lhe family health progranlIne does more for whoever needs more. The experience of the BH Telemedicíne implementation provides guidance for the future: • potential for innovation in the public network .. standards li'le interaction between teaching and the assistíng practíce of the health services • improvements in the assisting stlUctme, with possibilities of reduced costs and better structuring of a multidisciplinary project of telemedicine. The main challenges regarding IT for prima!)! care are: 1. To improve IT in primary care centres, rather than at the central leveIs of health system rnanagement. 2. To estimate standardization and compatibility between national health informa­ tion systems, especial1y through \veb-based tools ratheI than the production of local soft\vare ar informatíoD systems. 3. To promote a wide professional training in IT as a strategy to facilitate its use in decision making for clinicaI practice, and to monitor and evaluate health pro­ grammes, focusing on people ratheI' than on tecnnology.

Overall, this wili require investment in IT anel telecommunications directed towards the basic health units. This investment should be made by mlluicipalities, but currently there are other priorities in the country' s publíc health and resources are scarce.

Further reading Araújo Novaes 1\,1, Pinto Barbosa AK, Soares de Araújo K et al. Experiences on the use of a second opinion software for the primary care. AiVílA Annu Symp Proc 2005: 889. Edworthy SM. Telemedicine in developing countries. BM] 2001; 323: 524-5. Goodman KW. Ethics and hea1th informatics: focus on Latin America and the Carib­ bea.'1. Acta Bioeth 2005; 11: 121-6. Avaiiablc at: www.scielo.cl/scielo. php ?pi d=S 1726-5 69 X2005000200002&scri pt=scCarttext&tlng==en.

40

Information technology for primary nealth care in Brazil

Rira AY, Lopes de Meno AN et aL Establishment ofthe Brazilian Telemedicine network for paediatric oncology. ] Telemed Telecare 2005: 11(Supp12): 51 -2. Rigby M. Impact of telemedicine fiust be defined in developing countries. EM] 2002; 324: 47-8.

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prirêary health in developing counVes. Trans Inf Technoi Blomed 2005; 9 66-72,

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