Case Study Formative Second Opinion: Qualifying Health Professionals for the Unified Health System Through the Brazilian Telehealth Program

Ana Estela Haddad, PhD,1 Mary Caroline Skelton-Macedo, PhD,1 Veroˆnica Abdala, MDS,2 Caren Bavaresco, PhD,3 Daniele Mengehel, MDS,1 Camilla Galatti Abdala, MDS,1 and Erno Harzheim, PhD3 1

Department of Orthodontics and Pediatric Dentistry, Telehealth and Teledentistry Center, Faculty of Dentistry, University of Sa˜o Paulo, Sa˜o Paulo, Brazil. 2 Latin American and Caribbean Center for Health Science Information Sao Paulo, Pan American Health Organization, Sao Paulo, Brazil. 3 Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.

to 238 questions (33.5%), followed by primary healthcare (90 questions) and then by subjects concerning oral health (68 questions) and nursery (39 questions). The structure and design of the FSO are also shown. Conclusions: The FSO helps professionals and health workers to use the already produced best evidence and scientific knowledge to solve their daily practice questions, improving, qualifying, and increasing the resolution of primary healthcare by the Unified Health System in Brazil. Oral health is frequently asked about by professionals, matching the high prevalence of oral disease in primary healthcare. Key words: telemedicine, e-health, health information management, education, medical, health education, formative second opinion

Introduction Abstract Background: The World Health Organization’s World Health Assembly WHA58.28/2005 Resolution recommends the adoption of e-health by health systems of State Members. The Brazilian Telehealth Program integrates the national policy of education for health that combines many strategies with complementary foci, including technical-level workers, undergraduate students of the 14 health professions, residency, postgraduate courses, support, and continuing health education at work. The Brazilian Unified Health System has approximately 1.5 million workers. The objectives of this work areas are as follows: to define a new concept, the so-called ‘‘formative second opinion’’ (FSO); to describe the methodology for its construction; and to show its structure as well as the number of FSOs already available, classified according to the field of knowledge. Materials and Methods: The Brazilian Telehealth Program was created in 2007 and has already offered around 41,000 teleconsultations. Based on their relevance and pertinence, 710 questions asked through teleconsulting by health professionals were selected. The questions were handled so that each question should not contain any specific information about patients, preserving professional confidentiality. For each question, a bibliographic review was performed and used to build a structured and standardized answer, based on the best available scientific and clinical evidence. Results: This question-and-answer combination, originated thru teleconsulting, created by the Brazilian Telehealth Program, was termed the FSO and has been made available, with open access for all health professionals, at the Web site of the Program. Among the total number of 710 FSOs, diagnosis and treatment support corresponded

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T

he World Health Organization’s World Health Assembly WHA58.28 Resolution (2005) recognizes the importance and potential application of e-health and recommends its adoption in a broad sense by health systems of State Members.1 In addition, the Global Observatory for e-Health provides a comprehensive and up-to-date source of national e-health policies, guidelines, and best practices concerning the subject.2 Khoja et al.3 conducted a structured literature review study in order to determine the scope of policy issues faced by individuals, institutions, or governments in implementing e-health programs. As a result, they provided a list of nine policy issues that should be understood and addressed by policy makers to facilitate the planning and implementation of e-health programs. We could identify some of these issues in the planning and implementing of the Brazilian Telehealth Program by the Ministry of Health, in particular, the diffusion of e-health and addressing the digital divide, but also networked care, interjurisdictional practice, policy goal-setting, evaluation and research, investment, and ethics and legal issues in e-health. The Brazilian policy for education and scale-up of human resources for health combines many strategies with different and complementary focuses. It includes technical-level workers, undergraduate students of the 14 health professions, residency, postgraduate courses, support, and continuing health education at work.4–6 This policy is part of the public Brazilian Unified Health System (Sistema U´nico de Sau´de [SUS]), which has approximately 1.5 million workers all over the country.7 All the programs that constitute this policy have as one of their common guidelines to promote the articulation of universities and

DOI: 10.1089/tmj.2014.0001

FORMATIVE SECOND OPINION

their undergraduate and postgraduate courses with health services as well as the integration between teaching–learning and healthcare. The educational policy aims at reorienting both education and the work of health professionals to consolidate the healthcare model of the SUS.4–6 The Brazilian Telehealth Program, which is part of this policy, was created by the Ministry of Health in 2007 with the main objective to qualify workers for the Family Health Strategy, strengthening primary healthcare (PHC). The Program has been planned with the focus on addressing the identified gap in the current health system and aiming at achieving clinical improvement and better quality of PHC. This is in accordance with the ‘‘needs-based evaluation theory.’’8 At the beginning of planning the Program, some public universities with experiences using information and communication technologies for tele-education and telecare, in particular, through their courses and professors of medicine, were identified and invited to participate in the Program. Afterward, in addition, nurses, dentists, and other professionals composed telehealth centers to offer workers at the Basic Units of Health teleconsulting about the cases they face in daily clinical practice. It is important to note that we are using the term ‘‘teleconsulting’’ and not ‘‘teleconsultation’’ because we are talking about a remote communication between two health professionals, and not between a health professional and a patient at distance. In the case of ‘‘teleconsulting, one health professional is asking the question, and he or she is responsible for the patient’s healthcare, at the service, and not remotely. In fact, the Brazilian National Council of Medicine has a legislation that does not allow ‘‘teleconsultation,’’ that is, a remote consultation between a physician and a patient at a distance. The Brazilian Family Health Strategy has 32,000 teams at work and covers more than 60% of the country’s 190 million inhabitants. Each team is composed of a doctor, a nurse, an auxiliary nurse, and six community health workers. About 18,000 teams are also integrated with dentists.9,10 The objectives of this work are as follows: to define a new concept, the so-called ‘‘formative second opinion’’ (FSO); to describe the methodology for its construction; and to show its structure and the number of FSOs already available, classified according to their main subjects. The FSOs are designed to answer the most frequently asked questions of health professionals working at the SUS in Brazil, recorded by the Brazilian Telehealth Program.

Materials and Methods The Brazilian Telehealth Program has already offered around 41,000 teleconsultings, asked for by health professionals, working at approximately 1,000 Basic Health Units located in nine out of the 27 Brazilian states. The questions were received and answered by one of the nine Telehealth Centers. All the five regions of the country (North, Northeast, Westcenter, Southeast, and South) had at least one of the nine Telehealth Centers. Considering all the questions from the Program as a whole, 710 questions asked by teleconsulting were selected, based on their relevance and pertinence to PHC. They were also frequently asked questions. There has not been a calculation

sample for the selection of the 710 questions. Although they came from all the nine Telehealth Centers, there are probably many other questions that would fit the same criteria. The questions were handled so that they should not contain any specific information about patients, preserving professional confidentiality. For each question, a bibliographic review was performed and used to build a structured and standardized answer, based on the best available scientific and clinical evidence. The databases used for the literature review were Medline and the journal portal of CAPES, the Ministry of Education. The resulting question-and-answer combination, originated through teleconsulting and created by the Brazilian Telehealth Program, was termed the FSO. The FSOs have been made available in open access at the Web site of the Program; this standardized procedure has been adopted nationally and is already established in the most recent legislation that also determined the expansion of the Program for the National Health System all over the country.11 The structure, content, and characteristics of the FSO result from the following steps of production: (1) selection of the questions, based on their relevance to PHC; (2) production of the structured answer, based on bibliographic search and the best available scientific evidence, as, for example, systematic reviews and clinical guidelines (in both the question and the answer, the identity and privacy of the patient must be preserved); (3) classification of the answer according to the level of the available scientific evidence; and (4) submission of the produced FSO in the following structure: . . . . . . .

Item Item Item Item Item Item Item

1: 2: 3: 4: 5: 6: 7:

question evidence-based answer bibliographic references professional that asked the question field of knowledge of the considered question author responsible for the answer date of publication of the FSO

The database with all FSOs is available free to search at the Web site of the Brazilian Telehealth Program.12

Results The 710 FSOs are classified in Table 1 according to each of their respective fields of knowledge. That process also analyzed what kind of professionals asked the questions. Considering the total number of 710 FSOs, diagnosis and treatment support corresponded to 238 questions (33.5%), followed by PHC (90 questions) and then by subjects concerning oral health (68 questions) and nursery (39 questions). The structure and design of the FSO are shown in an example at Table 2. The teleconsultings offered by the Brazilian Telehealth Program aim, in the short term, at solving the health professional’s doubt and, in the long term, at contributing to increase the clinical effectiveness and quality of PHC. This is made possible by means of the educational characteristics of the complementary information made available by the FSO. The process of requesting the teleconsulting is conducted by health professionals working at SUS and the teleconsultors from the

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Table 1. Number and Percentage of Formative Second Opinions According to the Field of Knowledge FIELD OF KNOWLEDGE OF THE AVAILABLE FORMATIVE SECOND OPINION

FORMATIVE SECOND OPINIONS AVAILABLE AT THE WEB SITE NUMBER

%

Diagnosis support

90

12.7

Treatment support

148

20.8

PHC

90

12.7

Nursery

39

5.5

Work process in PHC

54

7.6

Health promotion and prevention

65

9.1

Oral health

68

9.5

Mother and child health

33

4.6

Mental health

26

3.7

Child health

18

2.5

Family health

2

0.3

Woman health

39

5.5

Adult health

7

0.9

Male health

4

0.6

21

2.9

6

0.8

Elderly health Adolescent health Total of formative second opinions available at the Web site

710

100

PHC, primary healthcare.

Telehealth Centers of the program.13 They are performed in either the store-and-forward or online (synchronous) mode, depending on the complexity of the case. Approximately 20% of the teleconsultings are synchronous, and 80% are asynchronous. In all cases, the teleconsulting is regulated by a professional with a background at PHC and follows the national legislation.11

Discussion When considering the Brazilian policy for education, development, and scale-up of human resources for health, one guideline is to integrate universities and health services, having the students developing their learning process at healthcare services as soon and as long as possible, interacting with health workers, under the supervision of university professors. Another directive is that the knowledge and research produced be of social relevance and may impact healthcare delivery for the Brazilian population. For that, the Ministry of Health created in 2003 in its structure the Secretariat of Management for Human Health Re-

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sources Labor and Education. This policy is run in partnership with the Ministry of Education. Also, the Ministry of Health of Brazil, through its Secretariat of Science and Technology, has been promoting and supporting research that can benefit and impact the SUS (termed the Research Program for the SUS).14 We consider it important to look at the research that has already been produced and to identify to what extent it is promptly available in order to impact healthcare delivery at the SUS. In this matter, the Brazilian Telehealth Program, when it created the concept and developed the FSO, focused on ‘‘building one more bridge’’ between universities and health services, bringing scientific knowledge to a new format, ready to be consumed by health professionals. It is important to clarify that the FSO brings the knowledge from scientific articles to a new format, ready to be used by health professionals, because it is (re)built to answer daily clinical practice questions. In fact, there are already evaluation studies showing the efficacy of the teleconsulting and the FSO. A study15 analyzed a group of 294 teleconsultings requested by physicians at the Telehealth Center of Rio Grande do Sul of the Brazilian Telehealth Program and found that each two teleconsultings avoided the referral of one patient to another health service, improving the clinical effectiveness and quality of PHC. The author also found that the most frequent subject of the questions asked by physicians at the state of Rio Grande do Sul (Brazil) was mental health. This led managers to a decision of reinforcing the planning of courses, learning objects, and FSOs in this field, targeting this group of physicians.15 It is interesting to note that dentistry is included in PHC by the SUS in Brazil, and this field of knowledge corresponds to a considerable number of questions asked by health professionals. A Brazilian study reported that out of 7,849 consultations occurring over a period of 2 weeks at the Community Service of the Conceic¸a˜o Hospitalar Group, caries and gingivitis were the second most prevalent problems.16 The Web site of the Brazilian Telehealth Program was first designed as a virtual health library in PHC, run by the Latin American and Caribbean Center on Health Science Information, from the Pan American Health Organization. The virtual health library is a wellestablished model from the Latin American and Caribbean Center on Health Science Information that has already many thematic libraries organized as a network.17 All of them have in common, as their target, the researchers, as they offer scientific articles. The virtual health library in PHC from the Brazilian Telehealth Program is also a virtual library integrated to this network. On the other hand, it represents an innovation because it has been designed as having health workers and not researchers as its target public. For that, it has organized scientific knowledge in the form of the FSO, based on the frequently asked and relevant questions in PHC, and is not like the other thematic libraries of this network, where researchers look for scientific articles. The other important issue to be considered is that the SUS has as one of its principles the integrality of healthcare (considering health in a holistic approach, involving all health professional and not only

FORMATIVE SECOND OPINION

Table 2. Example of the Formative Second Opinion, Showing Its Structure and Design16 DESCRIPTION Date

August 8, 2013

What is the meaning of ‘‘immature squamous metaplasia’’ as the outcome of Papanicolau exam (Pap smear)?

Immature squamous metaplasia as a result of cervical cytology test means a repair that arises from mucosal lesions of the neck to expose the stroma and can be caused by any agent that causes an inflammatory process (candidiasis, bacterial vaginosis, etc.) and is generally the final stage. Please follow the routine Pap screening, and the patient need not undergo any treatment or be referred to the focal specialist. In Brazil, as determined by the Ministry of Health and INCA, the cytological examination of the cervix should be prioritized for women 25–60 years, once a year, and after two consecutive negative annual exams, every 3 years. Many actions are performed in primary healthcare for the prevention and control of cervical cancer, ranging from care for the prevention of sexually transmitted diseases, until directed for early cancer detection: information to the public on the screening, identification of the female population in the priority age group, identification of women at increased risk (access), calling for examination, blood sampling cytology, and identification of faulty recall (longitudinality), receipt of reports, identification of women with positive screening for the surveillance case, guidance and referral of women to secondary-level healthcare service cover assessment cytology in the area, assessing the quality of data collection and supervision of technicians for collecting, planning and execution of actions in the area of responsibility in the health outcomes team, dedicated to improving the coverage of the exam. The team is also responsible for surveillance of cases referred for diagnostic confirmation and treatment, identification of gaps in access, and closure of cases. They can also offer different types of support to patients in curative or palliative treatment. The incidence of cervical cancer in women under 24 years is very low; most cases are diagnosed in stage I, and tracking is less efficient to detect them. These data explain why the anticipation of the early screening of women 20–25 years of age has very limited impact and is reported as not advantageous. Moreover, the earlier onset represents a significant increase in diagnoses of low-grade lesions, considered not only the precursor and representative cytological manifestation of HPV infection, which are likely to result in regression and a significant number of colposcopy and procedures unnecessarily. These facts have been considered in recommendations of various countries over the beginning of the trace. International recommendations have been delaying the start of tracking cervical cancer. In the United States, the American Cancer Society indicated screening beginning after the onset of sexual activity. Subsequently it began to recommend it to be done from 18 years of age, and in 2002 it began to adopt 3 years after the onset of sexual activity, with a maximum age of 21 years. In 2009, the American College of Obstetricians and Gynecologists eliminated the rule of 3 years after the onset of sexual activity and began to recommend screening only from the age of 21 years. In Europe, tracking cervical cancer starts preferably between 25 and 30 years of age, with some regional variations. There is less objective evidence about when women should terminate the collection of specimens for Pap screening in the screening of cervical cancer. There is a tendency to extend the interval between collections in women with advanced age, as proposed by the current World Health Organization recommendations. Anyway, even in countries with high population longevity, there are no objective data that screening is useful after 65 years of age.

Selected bibliography

National Cancer Institute (Brazil). Brazilian guidelines for the screening of cervical/National Cancer Institute cancer. Rio de Janeiro: General Coordination of Strategic Actions, Network Support Division of Oncology Care, INCA, 2011.

Category of evidence

Grade B recommendation

Requesting professional

Nurse and physician

Key words

Metaplasia, cancer of the cervix

CIAP1 descriptors

X34

Teleconsultor

Telehealth Team, Telehealth Center from the Federal University of Rio Grande do Sul, Brazil

HPV, human papillomavirus; INCA, National Cancer Institute.

the physician) that must be achieved by the broad concept of health and its social determinants, and also through healthcare delivery in the multidisciplinary approach. The teleconsulting at the Brazilian Telehealth Program is available for all health professionals and workers, that is, the physician, the nurse, the dentist, the auxiliary nurse, and the community health worker. The answer is also offered by a professional who has the relevant competency for the subject that is being dealt with. Also, the orientation is reinforced in a way that each professional has a clear vision of its competencies. This perspective allows for better teamwork, allowing members to improve their understanding of the competencies of other professions, seeking for a more integral healthcare for each patient.

It is noteworthy that recently, after 7 years of its implementation all over the country, the Brazilian Telehealth Program has been recognized by the Pan American Health Organization as an international model of telehealth.18 Many other aspects involving the planning and implementation of the Brazilian e-health policy, integrated by the Brazilian Telehealth Program, but also many other initiatives linked to the SUS, are still to be approached. One of them would be to investigate the possibility of applying the e-Health Evaluation Tool8 to the Brazilian Telehealth Program, in an effort to comprehensively evaluate what we have already achieved and what are the challenges we still have to face to move forward in strengthening the Brazilian e-health policy to better support our SUS.

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Conclusions The FSO, derived from teleconsultings, helps professionals and health workers to use the already produced best evidence and scientific knowledge to solve their daily practice questions, improving, qualifying, and increasing the resolution of PHC at the SUS in Brazil. Considering the main subjects of PHC, oral health is frequently asked about by professionals, matching with the high prevalence of oral disease seen in PHC.

Disclosure Statement No competing financial interests exist. REFERENCES 1. World Health Organization. WHA 58.28 Resolution of 2005. Available at http:// apps.who.int/iris/bitstream/10665/20378/1/WHA58_28-en.pdf (last accessed January 4, 2014). 2. World Health Organization. Global Observatory for e-Health, 2005. Available at www.who.int/goe/en/ (last accessed January 4, 2014). 3. Khoja S, Durrani H, Nayani P, Fahim A. Scope of policy issues in ehealth: Results from a structured literature review. J Med Internet Res 2012;14:e34. 4. Ferreira JR, Campos FE, Haddad AE, Cury G. The challenge of improving health and medical care through undergraduate medical education "PRO-SAUDE." Educ Health Change Learn Pract 2007;20:75. 5. Campos FE, Brenelli SL, Lobo LC, Haddad AE. The single health system as a school: Social responsibility towards the population’s health care and the education of future health professionals. Rev Bras Educ Med 2009;33:513–514. 6. Amaral E, Campos HH, Friedman S, Morahan PS, Araujo MNT, Carvalho Ju´nior PM, Bollela V, Ribeiro MGF, Mennin S, Haddad AE, Campos FE. An educational international partnership responding to local needs: Process evaluation of the Brazil FAIMER Regional Institute. Educ Health 2012;25:116–123. Available at https://www.researchgate.net/publication/233619538_An_Educational_ International_Partnership_Responding_to_Local_Needs_Process_Evaluation_ of_the_Brazil_FAIMER_Regional_Institute (last accessed January 4, 2014). 7. Haddad AE, Morita MC, Pierantoni CR, Brenelli SL, Passarella TM, Campos FE. Undergraduate programs for health professionals in Brazil: An analysis from 1991 to 2008. Rev Saude Publica USP 2010;44:383–389. 8. Khoja S, Durrani H, Scott R, Sajwani A, Piryani U. Conceptual framework for development of comprehensive e-health evaluation tool. Telemed J E Health 2013;19:48–53. 9. Campos FE, Haddad AE, Chao LW, Alckmin MBM, Cury PM. The National Telehealth Program in Brazil: An instrument of support for primary health care. Latin Am J Telehealth 2009;1:39–52. Available at www.laboratoriotelesalud .com.br/padrao/index.php/br/noticias/1-timas-notas/47-latin-americanjournal-of-telehealth (last accessed January 4, 2014). 10. Haddad AE. Experieˆncia Brasileira do Programa Nacional Telessau´de Brasil. In: Mathias I, Monteiro A, eds. Inovac¸a˜o Tecnolo´gica em Educac¸a˜o e Sau´de, Vol. 1.

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Rio de Janeiro: Editora UERJ, 2012:12–44. Available at www.telessaude.uerj.br/ goldbook/apresentacao (last accessed January 4, 2014). 11. Ministry of Health, Brazil. Edict number 2546, October 27, 2011. Increases the coverage and the scope of the Brazilian Telehealth Program from PHC to the entire network of SUS. Available at http://bvsms.saude.gov.br/bvs/saudelegis/ gm/2011/prt2546_27_10_2011.html (last accessed January 4, 2014). 12. Programa Nacional de Telessau´de/Biblioteca Virtual em Sau´de—Atenc¸a˜o Prima´ria a` Sau´de. Available at http://pesquisa.bvs.br/telessaude/?where = BLOG (last accessed January 4, 2014). 13. Schmitz CAA, Harzheim E. Manual de telessau´de para atenc¸a˜o ba´sica/atenc¸a˜o prima´ria a` sau´de. 2012. Telessau´deBrasil Redes. Available at www.telessaudebrasil.org.br/ (last accessed January 4, 2014). 14. Ministry of Health, Brazil. Research for SUS Program—PP SUS. Available at http://portal2.saude.gov.br/sisct/ (last accessed January 4, 2014). 15. Castro Filho E. Telessau´de no apoio a me´dicos de atenc¸a˜o prima´ria [Doctoral thesis]. Porto Alegre, Brazil: Programa de Po´s-Graduac¸a˜o em Epidemiologia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, 2011. Available at www.lume.ufrgs.br/bitstream/handle/10183/53156/ 000854108.pdf?sequence = 1 (last accessed January 4, 2014). 16. Takeda AS. Organizac¸a˜o de servic¸os de atenc¸a˜o prima´ria a` sau´de. In: Duncan B, Schmidt MI, Giuliani ERJ, eds. Medicina ambulatorial: Condutas de atenc¸a˜o prima´ria baseadas em evideˆncias, 3rd ed. Sa˜o Paulo: Editora Artmed, 2006: 76–87. 17. Biblioteca Virtual em Sau´de. Available at www.virtualhealthlibrary.org (last accessed January 4, 2014). 18. Ministry of Health, Brazil. Available at http://portalsaude.saude.gov.br/ index.php/cidadao/principal/agencia-saude/8494-opas-reconhece-telessaudebrasil-como-referencia-mundial (last accessed November 16, 2014).

Address correspondence to: Ana Estela Haddad, PhD Faculdade de Odontologia Universidade de Sa˜o Paulo Avenida Prof. Lineu Prestes 2227 Cidade Universita´ria Sa˜o Paulo, SP, 05508-900 Brazil E-mail: [email protected] [email protected] Received: January 5, 2014 Revised: May 1, 2014 Accepted: May 7, 2014

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Formative second opinion: qualifying health professionals for the unified health system through the Brazilian Telehealth Program.

The World Health Organization's World Health Assembly WHA58.28/2005 Resolution recommends the adoption of e-health by health systems of State Members...
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