Expediente / Expedient / Expediente Latin American Journal of Telehealth A Publication of Medical School of Federal University of Minas Gerais (Brazil) , Laboratory of excellence and Innovation in Tele- health and National Center for Technological Excellence in Health (Mexico) Una publicación de la Facultad de Medicina de la Universidad Federal de Minas Gerais (Brasil), Laboratório de Excelencia e In- novación en Telesalud y Centro Nacional de Excelencia Tecnologica en Salud (Mexico) Uma publicação da Faculdade de Medicina da Universidade Federal de Minas Gerais (Brasil) , Laboratório de Excelência e Inova- ção em Telessaúde e Centro Nacional de Excelência Tecnológica (México) Editor Chefe Editorial Board Normalização Bibliográfica Editor in Chief Cuerpo Editorial Bibliographic Standardization Redactor jefe Adriana Velazquez - México Normalización Bibliográfica Alexandra Monteiro - Brasil Cláudia dos Santos Roberto Nascimento Alaneir de Fátima dos Santos (UFMG) - Brasil Alexandre Taleb - Brasil Aldo von Wangeheim - Brasil Projeto Gráfico e Produção Editorial Co-editor Alvaro Pacheco - Portugal Graphic Design & Editorial Production Co-editor Andrés Bas Santa-Cruz - Espanha Diseño Gráfico e Producción Editorial Co-editor Andrés Martínez Fernández - Espanha Folium Editorial Humberto José Alves (UFMG) - Brasil Angélica Baptista Silva - Brasil www.folium.com.br Adrian Pacheco Lopez (CENETEC) - México Blanca Luz Hoyos - Colômbia [email protected] Beatriz Faria Leão - Brasil Centro de Comunicação Social da Faculdade de Editor Executivo Carmem Verônica Mendes Abdala - Brasil Medicina da UFMG Camilo Barrera Valencia - Colômbia Coordenação / Coordination / Coordinación: Editor gerente Chao Lung Wen - Brasil Gilberto Boaventura Carvalho Manager Claudio Pelaez Veja - Portugal Atendimento Publicitário / Advertising Professional Mônica Pena de Abreu (UFMG) - Brasil Cleinaldo Costa - Brasil / Servicio de Publicidad: Ingred Souza Mauricio Velazquez Posadas (CENETEC) - Mexico Don Newsham - Canadá Designer Gráfico / Graphic Designer / Diseño Gráfico: Luiz Romaniello Eliane Marina Palhares Guimarães - Brasil Editores Administrativos Eligia Díaz - Panamá Periodicidade Administrative Editors Érica Couto Brandão - Brasil Frequency Erno Harzheim - Brasil Editores Administrativos Periodicidad Francisco G. La Rosa - USA Neuslene Rievrs de Queiróz - Brasil Quadrimestral Fernando Moralles - Venezuela Samuel Gallegos Serrano - México Gerald Egmann - Guyane Versão Online Berenice Figuero Cruz - México Gilberto Antônio Reis - Brasil Online Version Giselle Ricur - Argentina Versión Online Apoio Tecnológico Gustavo Cancela e Penna - Brasil www.revistatelessaudela.com Technological Support Ilias Schpazidis - Alemanha Suporto Tecnológico Ilara Hammerli Sozzi de Moraes - Brasil Início da Publicação Kaiser Bergman Garcia e Silva - Brasil Luiz Ary Messina - Brasil First Publication Luiz Fernando de Paiva Silva Gonçalves - Portugal Primera Publicación Magdala de Araújo Novaes - Brasil v.1, n.1, jan./abr. 2009 Conselho Deliberativo Maria Angela Elias Marroquin - El Salvador Council Board Marcus Luvisi - Itália Correspondência e Artigos Consejo Deliberativo Maria do Carmo Barros de Melo - Brasil Correspondence and Articles Alzira de Oliveira Jorge - Brasil Mário Paredes - Equador Correspondencia e Artículos Ana Estela Haddad - Brasil Nancy Gertrudiz Salvador - México Revista Latino-americana de Telessaúde Blanca Luz Hoyos - Colômbia Paulo Roberto de Lima Lopes - Brasil Av. Professor Alfredo Balena, 190 - 6° andar - Phillipe De Lorme - França Sala 622 Cláudio de Souza - Brasil Rosália Morais Torres - Brasil Centro - Belo Horizonte, MG - Brasil Cleinaldo Costa - Brasil Tarcizo Afonso Nunes - Brasil CEP: 30130-100 Francisco Eduardo Campos - Brasil Theo de Vries - Holanda Telefax: 5531 3409-9636 Fabiano Geraldo Pimenta Junior - Brasil Victor Ribeiro Neves - Brasil e-mail: [email protected] Luiz Ary Messina - Brasil Ville Morocho Zurita - Equador Márcio Luiz Bunte de Carvalho - Brasil Zilma Reis - Brasil Telefax: 5531 3409-9636 Sergio Dias Cirino - Brasil Vanessa Lima - Brasil E-mail: [email protected] Solange Cervinho Bicalho Godoy - Brasil Tarcizo Afonso Nunes - Brasil Pedro Ramos Contreras - México CENETEC Tarcisio Arrighini - Itália Juan Adalberto Anzaldo Moreno - México Endereço/Dirección/Address: Paseo de la Re- Miriam Silva Flores - Mexico Teresita de Jesus Cortés Hernandez - México forma 450, Col. Juárez, Delegación Cuauhtemoc, Corpo Editorial Galo Berzaín Varela - México Cd de México, México CP 06600 Latin Am J telehealth, Belo Horizonte, 2017; 4 (2): 104 - 195 Summary / Sumario / Sumário Latin American Journal of Telehealth Articles 161 Indicators elaboration in a Artículos Mexico teleconsulting state pro- Artigos gram Ejercicio de indicadores de un 104 The National Program Telehealth Brazil programa estatal de teleconsultas Networks: a historic and situational perspec- en México tive Mauricio Velázquez Posada, Miriam Silva Flores, Adrián Pacheco López El Programa Nacional Telesalud Brasil Redes: una perspectiva histórica y situacional 173 Teleconsultations in pediatrics: Thais Coutinho de Oliveira, João Geraldo de Oliveira experience in the state of Minas Junior, Graziela Tavares, Anna Francine Gonçalo Gerais, Brazil Rigato, Francy Webster de Andrade Pereira, Fabio Teleconsultorias en pediatría: Fortunato de Brasil Carvalho experiencia en el estado de Minas 124 Health education and the medias: the Gerais,Brasil results of an extension program focused in Maria do Carmo Barros de Melo, 7 h audiovisual production in São Luís, Maranhão, Neuslene Rievrs de Queiroz, Humberto t 1 Brazil José Alves, Gustavo Cancela e Pena, l Rosália Morais Torres, Claudio de Souza a Formación En Salud sanitaria y los medios: los 0 resultados de un proyecto de extensión enfocado e 2 en la producción audiovisual en São Luís, Maran- Brief Communication h Communicación breve hão, Brasil e o Caio Graco Bruzaca, Philippe Costa Carvalho, Comunicado breve Marcone Cruz Moreno Soares, Yuri Armin Crispim el st dSee rMlyjoarnaee sP,e Fnehran aHnedrom Aannoto Nniuon Gesu i,m Jaorsãée sA lRbaumquoesr,q ue 183 Best Practices in Telehealth of T de Figueiredo Neto, Ilana Mirian Almeida Felipe Colombia o Mejores Practicas en Telesalud de Co- J g 2 140 3. Telephysiotherapy Telehealth Center lombia A Rio de Janeiro’s asynchronous webseminars Blanca Luz Hoyos Henao ° m usage analysis / n Análisis de la utilización de webseminarios asín- Report A t cronos del Telefisioterapia Núcleo Telesalud Rio de Informe s | Janeiro Informe u n 4 Danielle de Mello Florentino, Kenia Maynard Silva, g Maria Isabel de Castro de Souza 194 Latin American Meeting of i t eScience BELLA -T 2017 u l a o 150 Telemedicine as a support tool in Primary Encuentro Latinoamericano de eCiencia A L v Health Care BELLA - T2017 Telemedicina como instrumento de soporte en la Luiz Ary Messina Atención Primaria a la Salud Franciele Guimarães de Brito, Aurélia Aparecida de Araújo Rodrigues, João Batista Destro Filho Latin Am J telehealth, Belo Horizonte, 2017; 4 (2): 104 - 195 English THE NATIONAL PROGRAM TELEHEALTH BRAZIL NETWORKS: A HISTORIC AND SITUATIONAL PERSPECTIVE Thais Coutinho de Oliveira Departamento de Atenção Básica/SAS/ Ministry of Health, Brazil João Geraldo de Oliveira Junior Departamento de Atenção Básica/SAS/ Ministry of Health, Brazil Graziela Tavares Departamento de Atenção Básica /SAS/ Ministry of Health, Brazil Anna Francine Gonçalo Rigato Residência de Saúde da Família na Ensp/Fiocruz, Brazil Francy Webster de Andrade Pereira Departamento de Atenção Básica /SAS/ Ministry of Health, Brazil Fabio Fortunato de Brasil Carvalho Departamento de Atenção Básica /SAS/ Ministry of Health, Brazil t The Programa Telessaúde Brasil Redes (Telessaúde) (free translation: Program Telehealth Brazil Networks (Telehealth)) became one c of the strategies used in the qualification of professionals and in health services’ actions that can positively impact the Sistema Único a de Saúde’s (SUS) (free translation: National Health Service) resoluteness. The tools used by Telessaúde (free translation: Telehealth) r t enable the opening of a quick and easy dialogue channel among professionals from the Atenção Básica (AB) (free translation: Prima- s ry Care) teams and teleconsultants so they can cooperate in the qualification of care in health and matrix-based strategies. The goal b of this article was to present a Telehealth’s implementation background through the succinct presentation of the program’s situation A by a report of the managing team workers’ experience, in the federal scope of Telehealth’s Primary Care. A document searching method was used in reports and informative documents. It is important to highlight that the Telehealth has a great potential of offer- ing services that can articulate the use of technological tools by the Primary Care teams through technical-scientific activities held by the Núcleos de Telessaúde (NTS) (free translation: Telehealth Centers). From the 47 implanted telehealth centers, 25 are intermunici- pal and 22 are state centers, 46 offered teleconsultancy service while 15 offered SOF’s activity and only 11 offered the telediagnosis whereas 24 centers offered tele-education activity. It was also reported that 08 centers are in the implementation phase. It is clear that the MS is adopting strategies for the program’s development in the country using normative, financial incentives, guidelines and parameters for the offer of their activities in addition to support for intermunicipal and state projects managed by the federal entities and education institutions in order to stimulate the progress of the project. Keywords: Telehealth; Telemedicine. n O Programa Nacional Telessaúde Brasil Redes (traducción libre: el programa nacional telesalud brasil redes): una perspectiva e histórica y situacional. m El Programa Telessaúde Brasil Redes (Telessaúde) (traducción libre: Programa Telesalud Brasil Redes (Telesalud)) se ha convertido en una de las estrategias utilizadas en la cualificación de los profesionales e de las acciones de los servicios de salud que pueden u impactar positivamente la resolución del Sistema Único de Salud (SUS). Las herramientas utilizadas por el Telesalud posibilitan la s apertura de un canal de diálogo rápido y fácil de los profesionales de los equipos de Atención Básica (AB) con teleconsultores, para e colaborar en la cualificación del cuidado en salud y organización de matriz. El objetivo de este artículo fue presentar un histórico de R la implementación del Telesalud, a partir de la presentación breve de la situación del programa a través del informe de experiencia de trabajadores del equipo gestor, en el ámbito federal de la AB, del Telesalud. Fue utilizado la metodología de investigación doc- umental en informes y documentos de información. Se destaca que el Telesalud tiene alto potencial de prestación de servicio que consiguen articular la utilización de herramientas tecnológicas por los equipos de AB, a través de actividades teórico-científicas, realizadas por los Núcleos de Telesalud (NT), de los 47 núcleos de Telesalud implantados, 25 son núcleos intermunicipales y 22 son núcleos estatales, siendo que 46 de estos ofrecen el servicio de teleconsultoría, mientras 15 ofrecen la actividad de teleeducación. Además, 08 núcleos están en fase de implementación. Se concluye que el MS viene adoptando estrategias para el desarrollo del programa en el país, a partir de normativas, incentivos financieros, directrices y parámetros para la oferta de sus actividades-fin, además del apoyo a los proyectos intermunicipales y estatales gestionados por los entes federativos y instituciones de enseñanza, a fin de estimular el avance del Programa. Palabras clave: Telesalud; Telemedicina. The National Program Telehealth Brazil Networds: A Historic and Situational Perspective o O Programa Nacional Telessaúde Brasil Redes: uma perspectiva histórica e situacional. m O Programa Telessaúde Brasil Redes (Telessaúde) tornou-se uma das estratégias utilizadas na qualificação dos profissionais e das ações dos serviços de saúde que pode impactar positivamente na resolutividade do Sistema Único de Saúde (SUS). As ferramen- u tas utilizadas pelo Telessaúde possibilitam a abertura de um canal de diálogo rápido e fácil dos profissionais das equipes de Atenção s Básica (AB) com teleconsultores, para colaborar na qualificação do cuidado em saúde e matriciamento. O objetivo deste artigo foi e apresentar um histórico da implementação do Telessaúde, a partir da apresentação sucinta da situação do programa através de re- R lato de experiência de trabalhadores da equipe gestora, no âmbito federal da AB, do Telessaúde. Foi utilizado o método de pesquisa documental em relatórios e documentos informativos. Destaca-se que o Telessaúde possui alto potencial de oferta de serviços que conseguem articular a utilização de ferramentas tecnológicas pelas equipes de AB, por meio de atividades técnico-científicas, realizadas pelos Núcleos de Telessaúde (NT), dos 47 núcleos de telessaúde implantados, 25 são núcleos intermunicipais e 22 são núcleos estaduais, sendo que 46 destes ofertam o serviço de teleconsultoria, enquanto que 15 oferecem a atividade da SOF, apenas 11 ofertam o serviço de telediagnóstico e 24 núcleos ofertam a atividade de tele-educação. Consta ainda que 08 núcleos estão em fase de implantação. Conclui-se que o MS vem adotando estratégias para o desenvolvimento do programa no país, a partir de normativas, incentivos financeiros, diretrizes e parâmetros para a oferta de suas atividades-fim, além de apoio aos projetos intermunicipais e estaduais geridos pelos entes federativos e instituições de ensino, afim de estimular o avanço do Programa. Palavras-chave: Telessaúde, Telemedicina. INTRODUCTION health Centers) combined with other mechanisms such as the incorporation of tools and access regulation practices, The Estratégia de Saúde da Família (ESF) (free trans- both oriented by clinical and referral protocols, healthcare lation: Strategy of Family Health) became the main way to center computerization with the use of electronic health re- reorganize the model of attention to health in Brazil that cords, processes of permanent education and the incorpo- gave emphasis to Primary Care and has consolidated itself ration of new technologies can expand the access, organize as State policy as well as a way to increase the population’s the costumer flow, qualify and expand the offer of health access to the integral and long-term health care. However, services, all of this seeking the resoluteness of actions and many critical knots are observed, especially when it comes health in Primary Care. to the resoluteness of the Rede de Atenção à Saúde (RAS) The tools used by Telehealth enable the opening of a (free translation: Healthcare Network). From this point on quick and easy dialogue channel between the Primary Care the Programa de Telessaúde Brasil Redes (Telessaúde) (free teams’ professionals and teleconsultants in order to coop- translation: Telehealth Program Brazil Networks (Telehealth)) erate in the qualification of healthcare and matrix-based became one of the used strategies in professionals’ qualifi- strategies. In this context the programs contributes to the cation and in health services actions that can positively im- qualification of necessary referrals for an equity, safe and pact the Sistema Único de Saúde’s (SUS) (free translation: agile access for costumers that need actions and services National Health Service) resoluteness. from other points of the RAS, with the possibility of short- This program makes use of information and communi- ening the number of referral requests and unnecessary test cation technologies to hold out long distance activities that through effective and without access restrictions practices. aim to improve population’s health by the qualification of Therefore the present article aims to present Telehealth’s SUS’s health care. It also presents potential to coordinate implementation records, accommodating the analysis of healthcare systems as of Primary Care1. the strategies undertaken since 2011 in order to raise the In the Política Nacional de Atenção Básica (PNAB) (free effectiveness of the Primary Care’s actions in coordinating translation: National Politics of Primary Care) the healthcare care and its challenges as of the succinct presentation of the coordination is laid down as a guideline being conceptually program’s situation. described as the elaboration, monitoring and management of singular therapeutic projects up to the organization of METHOD user flow between RAS’s2 points of attention. Primary Care should act as the communication center between RAS’s at- This is an experience report from the managing workers tention points, establishing a horizontal relationship that is team in the federal scope of Telehealth’s Primary Care. A continuous and integrated in the responsibility of care. documentary research method was used to outline in a suc- One of the biggest challenges of Primary Care is its reso- cinct way the current state of the program’s implementation luteness as of the expansion of its caring capacity. In this re- including a brief historical review of the program in Brazil gard the Núcleos de Telessaúde (NT) (free translation: Tele- since 2011. Latin Am J telehealth, Belo Horizonte, 2017; 4 (2): 104 - 113 105 The National Program Telehealth Brazil Networds: A Historic and Situational Perspective The document search doesn’t require contact with the To Bardin5, with the beginning of the activity of content investigation subjects and enables an in-depth reading of analysis one should firstly establish contact and know the the sources. It is similar to á bibliographic research; however analyzed material letting him or herself to be invaded by it differs from the sources’ nature since the documentary impressions and orientations. Therefore part of the material research proposes the use of materials that haven’t had an was selected and grouped from clippings and the extraction analytical treatment or that can still be reworked according of the most relevant ideas, according to its similarity with to the investigation subjects3. what was described in the investigated documents This study was realized through reports and informa- Through reading and rereading the material that was tive documents about the NT’s deployment that were either considered relevant the parts were grouped according to elaborated or sent to the Departamento de Atenção Bási- the familiarity and the dimensions in which the themes ap- ca do Ministério de Saúde (DAB/SAS/MS) (free translation: peared; categories for analysis and discussions arose by The Ministry of Health Primary Care Department) and by the this exercise. Therefore the following categories were elab- means of descriptive reports from the Sistema de Monitora- orated: 1) Instituição do Programa Telessaúde Brasil Redes mento e Avaliação dos Resultados do Programa Telessaúde (free translation: Telehealth Brasil Networks Program Institu- (SMART) (free translation: Monitoring and Evaluation of the tion); 2) Estratégias e Serviços Implementados (free trans- Telehealth’s Program Results Sistem). lation: Strategies and Implemented Services); and 3) Atual Through quantitative and qualitative approaches data estágio de implementação do Programa Telessaúde Brasil collection and analysis was observed. They were collected Redes (free translation: Current stage of implementation of in the SMART and the relevance of the information described the Telehealth Brazil Networks Program). in the NT’s implantation reports as well as the normative that rule the Telehealth from the accurate and critical glaze from DISCUSSION the documental source were also observed. The combined research is based in Santos’s4 studies 1) Establishment of the Programa Telessaúde Brasil when it defends that: Redes (free translation: Telehealth Brazil Networks Program) In the combined method the interconnection of many The Telehealth was established by the Secretaria de information that can be compared allows a bigger opening Gestão do Trabalho do Ministério de Saúde (SGTES/MS) of the investigation’s perspective as well as the deepening (free translation: Health Management Secretariat of the Min- of the data analysis. The complementarity of procedures istry of Health) in 20076 and was called Programa Nacional creates better conditions for overcoming possible Telessaúde (free translation: Telehealth National Program) in distortions and errors during the research process. In 2011; subsequently it was rectified as Programa Nacional the face of many methodological options the matter of Telessaúde Brasil Redes (free translation: National Program reliability and data validation is set up front, both directly Telehealth Brazil Networks)1. related to the quality of the research. The Telehealth in Primary Care was established by means of the Ministerial Order GM/MS nº 2.554 from October 28 of 2011 as a part of the Programa de Requalificação das UBS The method was divided in two distinct moments; the (free translation: Healthcare Center Requalification Program) first one was the document and data collecting from the (associated with computerization) as well as a part of the information system while the second one was the content Programa Nacional Telessaúde Brasil Redes7 (free trans- analysis. Therefore the documents collection in an explora- lation: National Program Telehealth Brazil Networks). This tory way by the researches started, with the selection and Ministerial order aimed to computerize Healthcare Centers critical analysis of relevant material which constituted the with the purpose of ensuring the connectivity and the use of pre-analysis phase. information technologies for qualifying actions and services In order to interpret the content from the documents that are offered by this attention point and integration them and collected data in a more elaborate form, it was from with other attention points that are part of the RAS; however the second moment that an analysis of the material’s con- tent began. In this phase the documents were studied and it would be necessary to develop matrix support and have analyzed thoroughly, describing and interpreting the content permanent education for Primary Care professional with of the messages and at the same time producing relevant NT’s support. theoretical knowledge. From then on the Program developed support activities 106 Latin Am J telehealth, Belo Horizonte, 2017; 4 (2): 104 - 113 The National Program Telehealth Brazil Networds: A Historic and Situational Perspective for attention to health and permanent education for the Pri- In 2011 the MS disposed about the deployment’s peak mary Care teams with the goal of improving the service’s values that would be passed on to the States concerning quality, raising the scope of offered actions and transforming the computerization component for the Telehealth in Primary the attention and the work process organization practices Care of the Requalifi cation of Healthcare Centers Program. through Teleconsulting, Segunda Opinião Formativa (SOF) Therefore the States were divided in fi ve groups according (free translation: Second Opinion Formational) and Teledi- to the size of the population or the number of Family Health agnosis. teams9. The resources destined to the projects would be In order to reach these goals the Telehealth in Primary passed on according to table 01: Care created municipal, intermunicipal and regional health Table 01 – Financial incentive passed on according to projects managed by Secretarias Municipais (free transla- the size of the Telehealth center and to the population tion: State Offi ces) or Secretarias Municipais de Saúde (free size or the nº of family health teams translation: Municipal Health Offi ces) some of these with partnerships with Instituições de Ensino Superior (IES) (free translation: Higher Level Educational Institutions). AAmmoouunntt ttoo bbee SSttaattuuss QQuuaannttiittaattiivvee NNºº ooff EESS FF The architecture of Telehealth’s projects was com- ppaasssseedd oonn** posed by Pontos de Telessaúde (free translation: Telehealth Points); these are health services equipped with connectivity I < 1.000.000 < 300 USD 239.563,05 from where teleconsulting and NT or Telehealth services are 1.000.000 to < requested, which are characterized as a clinical-assistance II 3.000.000 300 to < 600 USD 638.834,80 support service and as a long distance matrix support that 3.000.000 to < 600 to < uses technical-pedagogical resources and offers telecon- III USD 958.252,20 7.000.000 1.200 sulting, telediagnosis and second opinion formational. Previously, Telehealth’s primordial action was telecon- 7.000.000 < 1.200 to USD IV 10.000.000 1.800 1.117.960,90 sulting and the teleconsulters would preferably be the own workers of the services network from the participating mu- nicipalities7. The desire was that more and more the profes- 10.000.000 or USD V 1.800 or more more 1.437.378,30 sionals that conducted the teleconsulting and SOF through the points connected to the NT were the own workers of the services networks from the participating municipalities Source: Decree/Portaria GM/MS nº 2.647, 07 November 2011. so that this activity became part of the scope of the activi- Currency quote USD 1,00 = BRL 3,13 ties developed by this professional and so that the project gained sustainability, accumulated intelligence and expertise The MS between 2011 and 2012 enabled municipal- by the services network. ities to receive resources from the Componente de infor- Therefore the new perspective would be to amplify the matização e Telessaúde na AB (free translation: Primary Primary Care’s resoluteness and to promote the integration Care’s Computerization and Telehealth Component)10,11 and passed on fi nancial resources around USD 8.624,00 to the with attention networks being pointed the perspective of Programa Nacional Telessaúde Brasil Redes (free transla- intra and interinstitutional articulation. Subsequently there tion: National Program Telehealth Brazil Networks)12,13. was a redefi nition and expansion of the program providing In 2014 there was the defi nition of the monthly defrayal’s the synchronic Teleconsulting services for the RAS and SUS fi nancial incentive cost according to the size of the center professionals (these services are the ones that happen in outlined in table 02; this established what would be com- real time by chat, web or videoconference) or asynchronous posed of a fi xed and variable component destined to the (services that happen through offl ine messages) Teledagno- intermunicipal and state NTs. However for qualifi cation for sis, SOF and Tele-education services8. Beyond that since the receipt of the referred incentive the States, Federal Dis- October 2011 the Coordenação Nacional do Programa (free trict and Municipalities that were NT headquarters should translation: Program’s National Management) is exercised in a fulfi ll some criteria described in decree. It was also instituted shared form inside the MS by the acticulation of two Depart- in the same decree the four types of NT sizes that depend ments, the SGTES and the Secretaria de Atenção à Saúde on the number of Primary Care teams that are participating (SAS) (free translation: Health Attention Secretariat) that mon- in the program; in addition the centers started to be qualifi ed itor the implementation and the operation of the Telessaúde as State, Municipal or Intermunicipal according to the link of Brasil Redes (free translation: Telehealth Brazil Networks)8. the headquarters management and its coverage14. Latin Am J telehealth, Belo Horizonte, 2017; 4 (2): 104 - 113 107 The National Program Telehealth Brazil Networds: A Historic and Situational Perspective State Health Bureau) with the defi nition and the agreement Table 02 – Cost of the monthly, fixed and variable finan- of care lines and/or priority specialties and their respective cial incentive that will be passed on to the type of the Tele- referral protocols15. health’s size according to the nº of teams participating in Regarding the values of the fi nancial incentive from the the program in each center. defrayal’s variable component associated with the part men- tioned in the number III above, they will be paid considering SSiizzee NNºº ooff FFiixxeedd TToottaall ooff MMaaxxiimmuumm MMaaxxiimmuumm-- ppaarrttiicc-- ccoomm-- VVaarriiaabbllee ttoottaall ooff ttoottaall ooff the size of the Telehealth Center and the total production of iippaattiinngg ppoonneenntt// CCoomm-- ddeeffrraayyaall// ddeeffrraayyaall// synchronous and asynchronous teleconsulting a month by tteeaammss mmoonntthh** ppoonneenntt// MMoonntthh** YYeeaarr** MMoonntthh** team, observing the following gradation: I – teleconsulting production by participating team: a) from 1 (one) to 1,9 (one I 80 to USD USD USD USD 199 7.985,44 7.985,44 15.970,88 191.650,44 point nine) teleconsulting a month by participating team: 60% (sixty percent) of “X”; b) from 2 (two) to 2,9 (two point II 200 to USD USD USD USD 399 9.582,52 9.582,52 19.165,04 198.038,79 nine) teleconsultings a month by participating teams: 80% (eighty percent) of “X”; c) more than 3 (three) teleconsultings III 400 to USD USD USD USD a month by participating team: 100% (a hundred percent) 599 11.179,61 11.179,61 22.359,22 268.310,62 of “X”. Moreover: II – teleconsulting production by the doctor IV 600 or USD USD USD USD of the team related to the care line or settled specialty a more 12.776,70 12.776,70 25.553,40* 306.640,70 month: a) from 1 (one) to 1,9 (one point nine) teleconsult- ings a month by participating doctor: 60% (sixty percent) of Source: Decree/Portaria GM/MS nº 2.647, 07 November 2011. Currency quote USD 1,00 = BRL 3,13 “X”; b) from 2 (two) to 2,9 (two point nine) teleconsultings a month by participating doctor: 80% (eighty percent) of “X”; Moreover in the case of NTs* counting on a minimum of and c) more than 3 (three) teleconsultings a month by par- 1.200 Primary Care teams for each extra number of three ticipating doctor: 100% (a hundred percent) of “X”. Single hundred Primary Care teams that participate in the Program paragraph. The variable “X” referred in article number 6 rep- the MS adds the value of USD 1.597,09 a month to the resents 20% (twenty percent) of the amount transferred to value of the type IV centers. The value of the variable com- the Center according to its size. ponent from the monthly defrayal fi nancial incentive is divid- ed considering the size of the center and criteria defi ned in 2) Estrategies and implemented services decree besides the monitoring of dimensions and indicators in the following way: I – by the activity of active and partici- The Telehealth has a high service offer potential that can pating Primary Care teams: until 40% (forty percent) of the articulate the use of technological tools by the Primary Care total value of the variable component that must be received; teams through technical-scientifi c activities realized by the II – by the defi nition and agreement of care lines and/or pri- NTs. For the monitoring and evaluation of the program these ority specialties: 20% (twenty percent) of the total value of activities are registered in an online platform on SMART. the variable component that must be received; and III – by Nowadays it is considered that 47 NTs were implanted the total production of teleconsulting: until 40% (forty per- between 2011 and 2012. In only two federative units (Amapá cent)of the total value of the variable component that must and Federal District) the center wasn’t implanted until March be received15. of 2017 and 08 deployments are still accounted for. In 2015 the defi nition of guidelines for Telehealth’s activ- In addition the receiving of resources from the parts of ities offer occurred, highlighting the end-activities such as the variable component demand having: I – a minimum of teleconsulting, the SOF, telediagnosis and tele-education16. 20% (twenty percent) of active participating teams a month; Teleconsulting is the main qualifi cation strategy being a way II – a minimum of 20% (twenty percent) of active partici- to clarify any doubts about management, conducts and clin- pating doctors a month; and III – realize at the very least 1 ical procedures, health actions and questions regarding the (one) teleconsulting a month by team 1 (one) teleconsulting work process. It works in a synchronous, real-time way, by a month by doctor from the team related to the care line chats, web conference, videoconference and free telephone or defi ned ad settled specialty15. There is the necessity of service (0800) or in an asynchronous way by offl ine mes- referral to the (DAB/SAS/MS), the Comissão Intergestores sages that are answered in up to 72h by consultants from Bipartite’s (CIB) (free translation: Bipartite Intergestor Com- the centers. mittee) resolution or the Colegiado de Gestão da Secretaria Another strategy adopted by the program is the SOF de Estado de Saúde do Distrito Federal (CGSES/DF) (free which is the systematic answer based in the Primary Care’s translation: Federal District’s Management Collegium of the authorizing role, in literary reviews, in the best clinical and 108 Latin Am J telehealth, Belo Horizonte, 2017; 4 (2): 104 - 113 The National Program Telehealth Brazil Networds: A Historic and Situational Perspective scientific evidences and in the questions generated from grama Nacional Telessaúde Brasil Redes (free translation: the teleconsultings. The Telediagnosis is another activity National Program Telehealth Brazil Networks), is oriented to that can be offered by the NTs and that configure a diagno- the management of scientific and technical information relat- sis supporting system; finally, Tele-education as an activity ed to Primary Care and to the provision of broad access to taught as distance learning by information and commu- scientific and technical knowledge that is updated, relevant nication technologies that serve as foundation to support and applicable to the Primary Care in the scope of the Na- the formation of the professionals that work at the National tional Healthcare Service. Healthcare Service. The technical grade further established The BVS also collaborates to the access increase and parameters that must be adopted by the NTs in order to to the visibility to the collections of educational resources offer the end-activities16. (ARE) from the UNA-SUS, develops and realizes capabilities In this regard the MS bets on the Telehealth as an ar- for the Telehealth Network and collaborates with the promo- ticulation tool between the Primary Care and specialized tion and communication actions of the Program in national attention stimulating a new way of communication among scope and from the Latin America and Caribbean region. these attention points by encouraging the NTs to integrate It is important to highlight the technical cooperation and themselves with the Regulation Center with the purpose of technical revision of the content, especially concerning the avoiding unnecessary referrals as well as qualifying the ac- courses realized by the AVASUS and UNASUS, such as the cess for the costumers from the National Healthcare Service teleconsultants and teleregulators in Mental Health course to specialized service. Within such concept referral proto- and the updating in the vector combat of the Aedes Aegypti. cols were elaborated with the specialties that had a higher demand in the Regulation Centers’ waiting lines, in addition 3) The current implementation stage of the Programa to the protocol of teleconsulting’s teleregulation with the pur- Telessaúde Brasil Redes (free translation: Telehealth Brazil pose of inciting the development of clinical guidelines and Networks Program) “in loco” regulation, shared definition of flows, discussion of cases and tele-education to settle or diminish the difficulties The service offer of each center depends on its structure of managing the waiting lines for specialized appointments. and capacity. It is known that nowadays not all of the im- Actions of long-distance courses for the formation of planted centers have actively exercised activities in all tele- teleconsultants and Telehealth managers were adopted health services. as well; technical support specialized in some university According to SMART data from the 47 implanted tele- centers, live and from a distance, for the implementation health centers, 25 are intermunicipal centers and 22 are projects; manual provision such as the Teleheath’s for the state centers, of which 46 of these offer the teleconsulting Primary Care/ Health Primary Care and the instructive’s for service while 15 offer SOF activities, only 11 offer telediag- the defrayal of the telehealth centers; answer protocols for nosis service and 24 centers offer tele-education activity. It is teleconsulting that aim to help the professionals from the also noted that 08 centers are in implantation phase. Primary Care teams to use the Teleconsulting resource, in- Figure 01 - Services offered by Telehealth in Brazil in the creasing the autonomy and resolutive capacity of the health period of jan/2016 to mar/2017 professionals; protocols of teleconsulting request that aim to help professionals linked to the Primary Care teams to 800.000 725.037 use the Teleconsulting resource which always starts the pro- 700.000 cesses by the applicant professional’s initiative, motivated 600.000 by everyday needs; software provision for the teleconsult- 500.000 ing flow; and the disclosure of the teleconsultings channel 400.000 via 0800 with the elaboration and distribution of stickers for 300.000 more than 40 thousand existing Healthcare Centers, state 200.000 secretariat and regulation centers. 100.000 79.112 27.372 1.389 Tutorials were elaborated with the purpose of offering Telediagnosis Teleconsultings Participation in Tele-activities in orientation about the available features by the MS’s Tele- Tele-education Education health Platform, such as teleregulator’s tutorials, applicant’s Source: SMART/Programa Telessaúde Brasil Redes/MS Currency quote USD 1,00 = BRL 3,13 tutorials, teleconsultant’s tutorials and manager’s tutorials. To support the teleconsulting, telediagnosis and tele-educa- According to figure 01 the most offered services by tion activities and to increase the SOF’s visibility, the Biblio- the NTs are the Telediagnosis ones, followed by Tele- teca Virtual em Saúde (BVS) (free translation: Health Virtual consulting, participation in Tele-education and Tele-ac- Library) - http://aps.bvs.br – with free and unrestrained ac- tivities in Education. The asynchronous activities are the cess to the contents, especially those produced by the Pro- kind mostly used by Primary Care professionals while Latin Am J telehealth, Belo Horizonte, 2017; 4 (2): 104 - 113 109 The National Program Telehealth Brazil Networds: A Historic and Situational Perspective accessing the teleconsulting services; however the syn- Figure 03 – Telediagnosis by equipment in Brazil in the chronous activity, by the 0800, is the least used one month of March of 2017. according to what we can observe in figure 02. It is im- portant to highlight that the production of synchronous 60.000 51.371 teleconsultings has as main character the Núcleo de 50.000 Telessaúde do Rio Grande do Sul (free translation: Rio 40.000 Grande do Sul’s Telehealth Center) through the service 30.000 0800 644 6543 still wasn’t integrated in the SMART’s 22.013 20.000 analysis. In the analyzed period the production referred 10.000 bfryo mth we hcicehn tneer awrlya s1 9o ft h3o0u,s0a5n3d r(e6a6l%ize) dw eterele scoolnicsiuteltdin bgsy Número Equipo O3d2ontologico Espi5rô3m5etro Derm2.a2t5o7cóspio Eletrocardiografo Monitor de ECG Brasil professionals (doctors and nurses) from Rio Grande do Sul (Table 3). Source: SMART/Programa Telessaúde Brasil Redes/MS Great part of the participation in the Tele-educa- Figure 02 - Number of Teleconsultings answered by type in tion activities is realized through webclasses/lectures Brazil in the period of Jan/2016 to Mar/2017 followed by courses and webseminars. It can also be observed in figure 04 little participation in matrix-based 90.000 strategies. The use of Tele-education tools is promis- 80.000 77.010 ing in the process of teaching-learning, in overcoming 70.000 physical and geographical barriers with the purpose 60.000 of updating and increasing the professional practice in health17. 50.000 40.000 Figure 04 – Number of participations by the kind of activity 30.000 according to Technical Note nº 50/2015 in Brazil in the pe- 20.000 riod of Jan/2016 to Mar/2017 10.000 1.539 566 0 Asynchronous Synchronous Phone(0800) Web Seminars 1.875 Source: SMART/Programa Telessaúde Brasil Redes/MS Webclasses/Lectures 19.502 Table 03 – Number of synchronous Teleconsultings an- Matrix-based 110 swered via 0800 by applicant federative unit in the period of Jan/2016 to Mar/2017 Discussion Forum 434 Course 5451 Norte Nordeste Centro-Oeste Sudeste Sul UF N UF N UF N UF N UF Acre 21 Alagoas 65 Distrito 266 Espirito 50 Paraná 503 Source: SMART/Programa Telessaúde Brasil Redes/MS Federal Santo Amazonas 34 Bahia 805 Goiás 767 Minas 2056 Rio 19901 Only 43,64% sent data for monitoring on the SMART Gerais Grande do Sul and moreover, in the last three months 63,83% of the Amapá 07 Ceará Mato 54 Rio de 362 Santa 1270 centers have hangs in the production shipping. In figure Grosso Janeiro Catarina do Sul 05 we can observe that a considerable percentage of Pará 79 Maranhão 27 Mato 334 São 1560 telehealth’s implanted points are inactive, making up a Grosso Paulo Rondônia 78 Paraíba 580 margin of 82,35%. Roraima 191 Pernam- 350 buco Tocantins 108 Piauí 61 Rio 26 Grande do Norte Sergipe 65 According to Figure 03 the most used equipment for Telediagnosis that is registered in the SMART is the ECG monitor, followed by the Electrocardiograph, dermato- scope, spirometers and dental equipment. 110 Latin Am J telehealth, Belo Horizonte, 2017; 4 (2): 104 - 113