Introduction

In several countries, alternatives to face-to-face medical consultation are already being used, despite their limitations, despite the need to investigate situations and contexts in which teleconsultation is safe and effective, and despite the political and corporate challenges for implementing it.¹ Video-based medical teleconsultation can present results equivalent to face-to-face consultation in providing care for people with diabetes mellitus, asthma, kidney disease, obstructive pulmonary disease, mental health conditions and chronic pain,² among other benefits.¹

In Brazil, the first restrictions on medical treatment without patients being physically examined were imposed in 1965.³ At the end of 2018, the Federal Council of Medicine published a resolution which regulated remote medical care, detailing premises, operational recommendations, and requirements for performing it. The publication of the resolution generated controversy and its subsequent suspension, subject to amendments.⁴ In March 2020, the Ministry of Health, on an exceptional and temporary basis, regulated telemedicine actions for remote interaction during the novel coronavirus (SARS-CoV-2) pandemic,⁵ infection with which causes severe acute respiratory syndrome (COVID-19). Teleconsultation has been used in several countries to provide medical care without risk of spreading the disease.

In May 2020, the Brazilian Ministry of Health presented a medical teleconsultation strategy for Primary Health Care (PHC), enabling health workers in Brazilian primary health care centers to perform virtual consultations in order to reduce the spread of SARS-CoV-2.⁶

Another possibility for teleconsultation, in addition to using it to provide Primary Care services, is to use the structure, reach and coverage of primary health care centers⁷ for specialized care, given the uneven distribution of specialist doctors.⁸ In this specialized teleconsultation model, service users would go to health centers to interact, by video call - in a safe environment supported by a technical health professional - with a specialist doctor situated in a remote location, but with access to the service user’s medical records.

This model ensures that the appointment with the doctor is made in advance, according to the doctor’s availability. Moreover, the presence of a technical professional at the moment of the consultation can help if a physical examination is needed when digital equipment is unavailable, as well as reducing the barrier of having a first virtual consultation with an unknown doctor. Studies have already linked the beneficial effects of teleconsultation when the physician is known to the service users.² As such, the presence of a health professional in person ensures (i) service user identification if there are no unified digital records, (ii) assistance in the use and connectivity of electronic devices, as well as promoting (iii) understanding the context of the service user’s life and improving (iv) communication - for greater service user trust and better decisions by the specialist.⁹

Health care needs and access to services are profoundly influenced by social determinants¹⁰ and, in order to propose alternatives to face-to-face consultation, several internet access and technological equipment scenarios, varying digital literacy levels, financial problems and health service user living conditions must be considered. Teleconsultation may not be adequate for all health service users or situations, such as when it constitutes an obstacle to access for the most vulnerable or those with difficulties in using technology.¹ The specialized teleconsultation model therefore depends on the resources available at the primary health care centers and integration between Primary and Specialized Care levels.

In order to indicate priority investment points for the implementing large-scale medical teleconsultation in the Brazilian public health system, the possible regional particularities and the different municipal population levels must be addressed. A study of primary health care center typology examined information and communication technologies using data from the 1^st cycle of the National Program for Primary Health Care Access and Quality Improvement (PMAQ-AB),¹¹ although its capacity for structural analysis was limited, since this cycle of the program only included data referring to the presence of computers with Internet access. The addition of new data in the 3^rd cycle of PMAQ-AB, the worldwide advancement of medical teleconsultation¹ and the progress made in regulating telemedicine actions in Brazil, driven by the SARS-CoV-2 pandemic, indicate the need to update current reality.

This study aimed to compare structure and work process conditions in Primary Care for implementing medical teleconsultation in municipalities in different regions and with different population sizes.

Methods

This is a cross-sectional study of Brazilian primary health care center structure and health team work process, according to the region of the country and municipal population size, aimed at implementing medical teleconsultation.

PMAQ-AB, the data source, is the main Primary Care evaluation strategy in Brazil, leading to access expansion and improvement in the quality of this health care level through financial transfers based on performance. PMAQ-AB researchers visit all primary health care centers and primary care staff throughout Brazil participating in the program to check for the presence of characteristics indicating improved Primary Care.¹² Among the teams working in the Brazilian National Health System in January 2018, 70% formalized their participation in the 3^rd PMAQ-AB cycle and were evaluated by the program.¹³

For this study, a ‘desirable structure’ for implementing teleconsultation consisted of equipment needed to perform an online video call;¹⁴ while a ‘minimal structure’ did not require peripheral equipment, since although it is necessary for making a video call, it is low-cost and easily obtainable.

When analyzing the work process of the health centers, it was established that there needs to be integration between Primary Care and Specialized Care, according to three minimal requirements: (i) use of the National Telehealth Program platform (a tele-education and tele-care initiative focused on the Family Health Strategy), considering the importance of transmitting and storing personal data on a secure platform, therefore assuming the teams’ familiarity with the use of technology to mediate clinical processes; (ii) existence of a specialized consultation supply and demand control center, to direct service users to other care points; and (iii) institutionalized communication flow between the Primary Care team and Specialized Care, to ensure integration between care levels.

The variables analyzed are described below.

The data used originated from the external evaluation of the 3^rd PMAQ-AB cycle, conducted in 2017-2018.¹⁵ Primary health care center structure profiles were described based on PMAQ-AB Module I, which aimed to evaluate the infrastructure conditions, materials, supplies and medication available at health care centers. In turn, the work process profile was described based on Module II, which aimed to evaluate the work process of the teams as well as organization of services and care practices.¹²

The analyses were presented by Brazilian regions and by municipalities according to their population size: (i) small municipalities with less than 25,000 inhabitants; (ii) medium-sized municipalities with 25,000 to 100,000 inhabitants; and (iii) large municipalities with over 100,000 inhabitants. To identify the odds of the minimal structure and minimal work process being present in a given region, the following were calculated for municipalities of similar size: (i) the odds ratio (OR) in bivariate form, comparing each region individually with the Southern region, since it presented the best results, both for structure and work process, and (ii) the 95% confidence interval (95% CI) for each OR. The analyses were performed with the Stata® statistical package (version 14.3).

The PMAQ-AB project was approved by the Research Ethics Committee of the Federal University of Pelotas Faculty of Medicine: Approval No. 2.453.320, issued on December 27, 2017.

Results

Data from the 30,346 primary health care centers that adhered to the 3^rd PMAQ-AB Cycle and 38,865 Primary Care teams distributed throughout Brazil were incorporated.

The Northern region’s large municipalities had a lower proportion of health centers with the desirable structure for implementing medical teleconsultation (1.2%); the highest proportion of health centers with this structure was found in small-sized municipalities in the Southern region (26.7%). As a whole, small-sized municipalities had a higher percentage of desirable structure throughout Brazil (small, 10.7%; medium, 8.3%; large, 7.2%) and, regionally, in the North, Midwest, Southeast and South. The exception was the Northeast, as shown in Table 1:

Regardless of population size, the Southern region concentrated the largest number of health centers with desirable structure, whereas the Northern region had the smallest number.

The Southern region had the largest number of health centers equipped with a computer with sufficient and continuous Internet access, this being a structure considered minimal for teleconsultation, ranging from 887 health centers in medium-sized municipalities (78.2%) to 1,587 health centers in small-sized municipalities (81.6%). The Northern region had the smallest number of health centers with minimal structure, varying from 288 health centers in medium-size municipalities (33.2%) to 336 health centers in large municipalities (45.3%). Microphones were the least found peripheral equipment in the health centers, being absent in 1,316 health centers (67.6%) in small-sized municipalities in the Southern region and in 809 health centers (93.3%) in medium-sized municipalities in the Northern region.

In four regions, the health centers of small-sized municipalities had higher minimal structure percentages, the exception being the Northern region (Table 1):

Between 18.9% of Primary Care teams in small-sized municipalities and 27.5% of teams in large-sized municipalities throughout Brazil had a minimal work process for implementing specialized teleconsultation, varying regionally: from 10.7% in small-sized municipalities in the North to 39.5% in large-sized municipalities in the South (Table 2). Small-sized municipalities in all regions, with the exception of the Midwest, had the lowest percentages of teams with minimal work process:

Throughout Brazil, 56.5% of teams in small-sized municipalities, 53.8% of teams in medium-sized municipalities and 48.1% of teams in large-sized municipalities used Telehealth. In the Southern region, 70.9% of teams in large-sized municipalities used this service, while in the Northern region, 27.3% of teams in large-sized municipalities used it. In the North, Northeast and Midwest regions, use of Telehealth was greater among teams in medium and small-sized municipalities, as shown in Table 2.

For Brazil overall, between 86% of health teams in small municipalities and 94.1% in medium-sized municipalities had a specialized consultation supply and demand control center for referring service users to other points of care. Between the regions, this proportion varied from 78.5% in small municipalities in the North to 95.4% in medium-sized municipalities in the South (Table 2).

Taking Brazil as a whole, between 31.9% of Primary Care teams in small-sized municipalities and 45.1% of these teams in large-sized municipalities had an institutionalized communication flow with Specialized Care, whereas the Southeast and Southern regions had higher percentages for all three municipal population sizes. Small-sized municipalities had the lowest percentages of teams with this institutionalized communication flow, regardless of the region (Table 2).

Large-sized municipalities in the North (OR=0.23 - 95%CI 0.19;0.28), Northeast (OR=0.25 - 95%CI 0.22;0.30) and Midwest (OR=0.30 - 95%CI 0.24;0.37) had lower odds of having the minimal structure necessary to implement teleconsultation, compared to municipalities in the South, as shown in Table 3. The Southeast region (large-sized [OR=0.52 - 95%CI 0.44;0.61]; medium-sized [OR=0.55 - 95%CI 0.46;0.64]; small-sized [OR=0.74 - 95%CI 0.64;0.85]) also had lower odds of having this minimal necessary structure, compared to the Southern region, although its odds were higher than that of other regions for all three population sizes.

Regardless of population size, the Northern region municipalities had lower odds of having adequate ‘work process’, according to the criteria adopted in this study, for implementing specialized teleconsultation (large-sized [OR=0.23 - 95%CI 0.19;0.27]; medium-sized [OR=0.29 - 95%CI 0.24;0.36]; small-sized [OR=0.42 - 95%CI 0.33;0.53]), and statistical difference was found.

Discussion

Most health centers did not have minimal structure for teleconsultation, with evident regional and population size inequalities: lower percentages for all population sizes in the North and Northeast regions; and higher percentages in small-sized municipalities in all regions except the North. Approximately one quarter of the teams had a minimal work process for implementing teleconsultation. The smallest percentages for this variable were found in the small-sized municipalities of four regions, with exception of the Midwest. Small-sized municipalities in all regions had higher odds of having a minimal work process. The North and Northeast were the two regions with municipalities that had the lowest odds of having a minimal structure for medical teleconsultation, regardless of municipal population size.

The data used in this analysis are dynamic. Health centers continuing to have appropriate equipment and continued internet access could have varied since the time the data were collected. It is known that computer availability at health centers varied from 88% in 2017 to 90% in 2018, and the proportion of health centers with internet access increased 7 percentage points in the same period,¹⁶ indicating that changes in structure were not substantial.

Increased internet access can be linked to federal government structural incentives, especially in certain regions and public health institutions lacking in technology, such as the National Broadband Plan (Decree No. 7.175 dated May 12, 2010), the Primary Care Informatization Strategy (Ministry of Health Ordinance GM/MS No. 1.412 dated July 10, 2013) and the Primary Care Health Center Informatization Program (Ordinance GM/MS No. 2.920 dated October 31, 2017). However, regional inequalities and the lack of a State policy for Digital Health persist. Progress with programs of this kind is usually interrupted by changes in government and policy redefinition, causing fragmentation, investment reduction and/or interruption in services offered. In 2018, only 13% of public health facility managers agreed that financial resources were sufficient for information technology investment needs.¹⁶

A similar scenario of inequality across the Brazilian regions has already been documented in other studies assessing regional health disparities.^17,18 Inequalities in access to information and communication technologies in Brazil are substantial: at the end of 2018, the Northern region had only 3.7% of the national total fixed broadband access.¹⁹ Solving this issue goes beyond the limits of Health. It requires investments and joint actions by multiple sectors, both public and private.

Small-sized municipalities were found to have better structure and work process. Since 2006, when the local health system management was put entirely under municipalities’ responsibility, it has been possible to observe how differences in management quality lead to different structures. It can be said that small municipalities have certain advantages over larger ones: they are less heterogeneous and have fewer services to manage, enabling greater commitment to Primary Care.²⁰

In this analysis, small and medium-sized municipalities in the North, Northeast and Midwest reported higher rates of Telehealth utilization, which suggests that it is possible to implement teleconsultation in places where there are fewer specialist professionals, surpassing the barrier of uneven geographical distribution of physicians in Brazil.⁸

The need for continued investment in telehealth, a resource used by approximately half of Brazilian health teams, is evident for the maintenance and expansion of their service package, including medical teleadvice, which was not initially envisaged due to regulatory restrictions. The population already makes use of several telemedicine and telehealth services offered by the regional centers, in a safe system, and only small adjustments to these platforms are needed in order to be able to perform teleconsultation. In 2018, 36% of primary health care centers used teleadvice (second opinion) and 27% used telediagnostic services.¹⁶

In order to implement teleconsultation, the adaptation of an existing and familiar platform, such as the Telehealth portal, can contribute to reducing certain limitations, already described in the literature, such as difficulties in use, concern with data safety, structural changes, difficulties in establishing new routines and resistance by health professionals and health service users.¹ Furthermore, integration of medical teleconsultation into a set of already existing services can strengthen the evidence for supervised self-management for chronic cases,² in accordance with the models presented in this study.

The presence of a service supply and demand control center in most Brazilian municipalities, ranging from 78.5% in the North’s small-sized municipalities to 95.4% in the South’s medium-sized municipalities, can facilitate directing patients to face-to-face consultation or to teleconsultation, according to pre-established protocols, as yet unavailable in Brazil. In some regions of Australia, for example, for specialties for which teleconsultation is provided, the choice is at the service user’s discretion, but relies on the health care team’s assessment of digital capacity and literacy, internet connection quality, and functionalities of the device used by the service user.²¹

When elaborating such teleconsultation protocols, choice of this type of service must be documented, in accordance with the General Data Protection Law, which provides for the handling of personal data, including in digital media, and is expected to come into force in May 2021.²² The need for Informed Consent signed by the service user in order for medical teleconsultations to be performed was stated in the revoked CFM Resolution No. 2.227, dated December 13, 2018,⁴ but is not mentioned in the new Ministry of Health Ordinance.⁵

Discussions and arrangements with regard to this theme are imminent and adaptation to different realities will be necessary. Accordingly, a unified proposal for teleconsultation, both for Primary and Specialized Care, covering the entire Brazilian territory, is likely to be exclusionary as it will favor municipalities with greater technological structure - namely small-sized municipalities and municipalities in the South -, aggravating regional disparities.

The next step would be to incorporate teleconsultation into care models, allowing for significant rearrangements and improvements in care and access to health and, therefore, beter clinical outcomes. The renowned Chronic Care Model,²³ in an updated version,²⁴ incorporated Digital Health elements to improve clinical outcomes, stressing the importance of effective communication using technological resources, digital education for self-care, and virtual communities for service user support.²⁴

In an ideal scenario, implementing teleconsultation in Brazil should undergo a slow and gradual transition, with incorporation of this novel approach of care provision as an additional service or partially replacing other services, and not just a total shift.¹ The potential for strengthening care networks would therefore be maintained, keeping Primary Care as coordinator of care and responsible for health within its coverage area, in order not to weaken comprehensive health care and the fundamental principles of an already-established care model.

In the current SARS-CoV-2 pandemic scenario, in some countries such as Italy, lack of telemedicine integration to health services has limited its capacity to contribute to the fight against COVID-19, with immeasurable consequences.²⁵ The teleconsultation experiences during the pandemic in Brazil for both suspected cases of the disease and for chronic cases follow-up have shown this model’s potential, although it had not been evaluated at the time this publication was submitted.

This study indicated that the desirable structure as a whole, consisting of all the equipment and internet connections necessary to perform teleconsultations, whether for Primary or Specialized Care, was very poor in the health centers of all municipalities and population sizes surveyed. It is noteworthy that investment must be prioritized in the North and Northeast regions, as well as in the medium and large-sized municipalities of the other regions where insufficient structural conditions for implementing medical teleconsultation are evident. Small-sized municipalities must commit to organizing their work processes. Besides the need to invest in research and development of medical teleconsultation, as well as in evaluating its pertinence and the challenges for its implementation on a large scale, taking regional particularities into account, regulation of its incorporation into care models also needs to be enhanced and implemented.