ABSTRACT

Objective:

to analyze telemedicine care in Vitória, Espírito Santo, Brazil, from April 2020 to March 2021.

Method:

based on Thied et al.’s dimensions of access, a case study was conducted using secondary data collected from the Bem Estar Network’s telemedicine reports. All 29 Basic Health Units of the municipality were included.

Results:

a total of 15,548 users were assisted in 21,481 consultations, 64% female (9,953) and 36% male (5,595). The most attended age group was 30-39 years old (19.5%). The number per 10,000 inhabitants for all causes ranged between 35.86/10,000 inhabitants from Oct-Dec/2020 and 65.75 from Apr-Jun/2020. Of these calls, 56% (11,946) targeted coronavirus (causes B342 and B972), ranging from 22.54 consultations per 10,000 inhabitants in Oct-Dec/2020 to 31.96 in Apr-Jun/2020.

Conclusions:

Results reflect the transformative impact COVID-19 had on telemedicine care as part of the first-line response to the pandemic in Vitória, Brazil. Inequalities in face-to-face access are reproduced in telemedicine, making it essential to maintain a strong relationship between the health system, health teams, and users when implementing telemedicine. Both forms of health care remain interdependent and complementary in the search to ensure equitable access to health.

KEYWORDS
Telemedicine; COVID-19; Health services accessibility; Primary Health Care; Health information systems

RESUMO

Objetivo:

analisar o atendimento pela telemedicina em Vitória/ES de abril/2020 a mar/2021.

Método:

estudo de caso ancorado na categoria acesso de Thiede et al. e em dados secundários. Utilizaram-se relatórios das consultas de telemedicina da Rede Bem Estar. Incluíram-se todas as 29 Unidades Básicas de Saúde do município.

Resultados:

no período foram atendidos 15.548 usuários, 64% do sexo feminino (9.953) e 36% do masculino (5.595), em 21.481 consultas. O grupo etário mais atendido foi o de 30-39 anos (19,5%). O número por 10.000 hab. para todas as causas oscilou entre 35,86/10.000 hab. de out-dez/2020 e 65,75 de abr-jun/2020. Destes atendimentos, 56% (11.946) foram coronavírus (causas B342 e B972), sendo, 22,54 consultas por 10.000 hab. de out-dez/2020 e 31,96 de abr-jun/2020.

Conclusões:

Os resultados refletem o impacto transformador da Covid-19 nos cuidados à saúde por telemedicina como parte da resposta de primeira linha à pandemia no município de Vitória/ES. As desigualdades no acesso presencial se reproduzem na telemedicina, o que torna imprescindível manter um relacionamento forte entre o sistema de saúde, as equipes de saúde e os usuários na implantação da telemedicina. As duas formas permanecem interdependentes e complementares na busca de garantia do acesso equitativo em saúde.

PALAVRAS-CHAVE
Telemedicina; Covid-19; Acesso aos serviços de saúde; Atenção Primária à; Saúde; Sistemas de informação em saúde

Introduction

The World Health Organization (WHO) declared COVID-19 a pandemic on March 11, 2020^{11 Organización Mundial de la Salud. Alocución de apertura del Director General de la OMS en la rueda de prensa sobre la COVID-19 celebrada el 11 de marzo de 2020. OMS; 2020. [acesso em 2020 dez 12]. Disponível em: https://www.who.int/es/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020.
https://www.who.int/es/director-general/...} . Since then, the disease has caused a global health urgency, with rapid evolution^{22 Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020; 323(13):1239.} and unprecedented serious consequences<sup>33 Bozorgmehr K, Saint V, Kaasch A, et al. COVID and the convergence of three crises in Europe. Lancet Public Health. 2020; 5(5):e247-8.

4 The Lancet. Covid-19 in Latin America: a humanitarian crisis. The Lancet. 2020; 396(10261):1463.-55 Abeles M, Pérez Caldente E, Porcile G. La crisis del Covid-19 y los problemas estructurales de América Latina y el Caribe: responder a la urgencia con una perspectiva de largo plazo. Rev Cepal. 2020; (132esp):153-84.</sup>. Hand hygiene, social distancing, isolation of cases and quarantine of contacts, restriction on non-essential travels, social protection measures covering policies aimed at economic protection, food security and school closures, among others, featured among the main measures used by countries to mitigate its spread and reduce health care system overload<sup>66 Anderson RM, Heesterbeek H, Klinkenberg D, et al. How will country-based mitigation measures influence the course of the COVID-19 epidemic? The Lancet. 2020; 395(10228):931-4.

7 Nussbaumer-Streit B, Mayr V, Dobrescu AI, et al. Quarantine alone or in combination with other public health measures to control COVID-19: a rapid review. Cochrane Infectious Diseases Group, organizador. Cochrane Database Syst Rev. 2020 [acesso em 2021 maio 17]; 4(CD013574):1465-1858 Disponível em: http://doi.wiley.com/10.1002/14651858.CD013574.
http://doi.wiley.com/10.1002/14651858.CD...

8 Ferguson N, Laydon D, Nedjati Gilani G, et al. Report 9: Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand. Reino Unido: Imperial College London; 2020. [acesso em 2021 maio 17]. Disponível em: http://spiral.imperial.ac.uk/handle/10044/1/77482.
http://spiral.imperial.ac.uk/handle/1004... -99 Brauner JM, Mindermann S, Sharma M, et al. Inferring the effectiveness of government interventions against COVID-19. Science. 2021; 371(6531):eabd9338.</sup>.

The mobility restrictions imposed to combat COVID-19 resulted in important changes in the organization and provision of health care services worldwide, mainly driven by digital health<sup>1010 Sarbadhikari S, Sarbadhikari S. The global experience of digital health interventions in COVID-19 management. Indian J Public Health. 2020; 64(6):117.

11 Murray CJL, Alamro NMS, Hwang H, et al. Digital public health and COVID-19. Lancet Public Health. 2020; 5(9):e469-70.

12 Mann DM, Chen J, Chunara R, et al. COVID-19 transforms health care through telemedicine: Evidence from the field. J Am Med Inform Assoc. 2020; 27(7):1132-5.

13 Martínez-García M, Bal-Alvarado M, Santos Guerra F, et al. Telemedicina con telemonitorización en el seguimiento de pacientes con COVID-19. Rev Clínica Esp. 2020; 220(8):472-9.-1414 Pérez Sust P, Solans O, Fajardo JC, et al. Turning the Crisis Into an Opportunity: Digital Health Strategies Deployed During the COVID-19 Outbreak. JMIR Public Health Surveill. 2020; 6(2):e19106.</sup>. Digital health refers to the use of technologies (digital, mobile and wireless) in implementing health goals^{1515 World Health Organization. Monitoring and evaluating digital health interventions: a practical guide to conducting research and assessment. Geneva: World Health Organization; 2016.}. It is also defined as thew use of information and communication technologies to improve human health, health care provision, and individual and population welfare^{1616 Kostkova P. Grand Challenges in Digital Health. Front Public Health. 2015 [acesso em 2021 abr 30]; (3). Disponível em: http://www.frontiersin.org/Digital_Health/10.3389/fpubh.2015.00134/full.
http://www.frontiersin.org/Digital_Healt...} .

The WHO describes digital health as the general use of Information and Communication Technologies (ICTs), covering: electronic health or eHealth^{1717 Organização Mundial da Saúde. 51º Consejo Directivo 63ª Sesión del Comité Regional de la OMS para las Américas: Estrategia y plan de acción sobre eSalud. Geneva: OPS; OMS; 2011.}, defined as the cost-effective and secure use of ICTs for health-related fields^{1515 World Health Organization. Monitoring and evaluating digital health interventions: a practical guide to conducting research and assessment. Geneva: World Health Organization; 2016.,1818 World Health Organization. The Fifty-eighth World Health Assembly. WHA58.28 eHealth. Geneva: World Health Organization; 2005.}; and also mobile health or mHealth, which describe the use of mobile and wireless technologies in public health^{1515 World Health Organization. Monitoring and evaluating digital health interventions: a practical guide to conducting research and assessment. Geneva: World Health Organization; 2016.,1919 World Health Organization. mHealth. Use of appropriate digital technologies for public health. Report No.: EB142/20. Geneva: World Health Organization; 2017.}. eHealth is an important reference term in this field<sup>1818 World Health Organization. The Fifty-eighth World Health Assembly. WHA58.28 eHealth. Geneva: World Health Organization; 2005.

19 World Health Organization. mHealth. Use of appropriate digital technologies for public health. Report No.: EB142/20. Geneva: World Health Organization; 2017.-2020 World Health Organization. Global diffusion of eHealth: Making Universal Health Coverage Achievable: Report of the Third Global Survey on eHealth. Geneva: Who; 2016.</sup>, but the preferred expression is digital health<sup>1515 World Health Organization. Monitoring and evaluating digital health interventions: a practical guide to conducting research and assessment. Geneva: World Health Organization; 2016.,2121 World Health Organization. Proyecto de estrategia mundial sobre salud digital 2020-2025. Geneva: WHO; 2020. [acesso em 2021 abr 3]. Disponível em: https://cdn.who.int/media/docs/default-source/documents/gs4dhdaa2a9f352b0445bafbc79ca799dce4d_02adc66d-800b-4eb5-82d4-f0bc778a5a2c.pdf?sfvrsn=f112ede5_68.
https://cdn.who.int/media/docs/default-s...

22 Banco Interamericano de Desarrollo. Gobernanza de la salud digital. El arte de la transformación de los sistemas de salud. 2020. [acesso em 2021 abr 2]. Disponível em: https://publications.iadb.org/es/gobernanza-de-la-salud-digital-el-arte-de-la-transformacion-de-los-sistemas-de-salud.
https://publications.iadb.org/es/goberna...

23 Organização Pan-Americana da Saúde. Saúde Digital: Uma estratégia para manter a assistência à saúde de pessoas que vivem com doenças não transmissíveis durante a pandemia de COVID-19. Washington, DC: OPAS; 2020. [acesso em 2021 fev 3]. Disponível em: https://iris.paho.org/handle/10665.2/52576.
https://iris.paho.org/handle/10665.2/525... -2424 Commission of the European Communities. On enabling the digital transformation of health and care in the Digital Single Market; empowering citizens and building a healthier society. Brussels: Commission of the European Communities; 2018.</sup> (OMS. Digital health. https://www.who.int/health-topics/digital-health#tab=tab_1). The present article uses both terms as synonyms when referring to the use of ICTs in health^{1717 Organização Mundial da Saúde. 51º Consejo Directivo 63ª Sesión del Comité Regional de la OMS para las Américas: Estrategia y plan de acción sobre eSalud. Geneva: OPS; OMS; 2011.,2121 World Health Organization. Proyecto de estrategia mundial sobre salud digital 2020-2025. Geneva: WHO; 2020. [acesso em 2021 abr 3]. Disponível em: https://cdn.who.int/media/docs/default-source/documents/gs4dhdaa2a9f352b0445bafbc79ca799dce4d_02adc66d-800b-4eb5-82d4-f0bc778a5a2c.pdf?sfvrsn=f112ede5_68.
https://cdn.who.int/media/docs/default-s...} .

Electronic health records, telehealth (including telemedicine), m-Health or health by mobile devices, eLearning (including distance learning), continuing ICT education, standardization and interoperability, etc., are among the main components of eHealth^{1717 Organização Mundial da Saúde. 51º Consejo Directivo 63ª Sesión del Comité Regional de la OMS para las Américas: Estrategia y plan de acción sobre eSalud. Geneva: OPS; OMS; 2011.,2020 World Health Organization. Global diffusion of eHealth: Making Universal Health Coverage Achievable: Report of the Third Global Survey on eHealth. Geneva: Who; 2016.}.

Of these, telehealth or the provision of treatment, diagnosis and image processing services via ICTs^{2525 Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health. 2020; 20(1):1193.,2626 Caetano R, Silva AB, Guedes ACCM, et al. Desafios e oportunidades para telessaúde em tempos da pandemia pela COVID-19: uma reflexão sobre os espaços e iniciativas no contexto brasileiro. Cad. Saúde Pública. 2020; 36(5):e00088920.}, particularly telemedicine or synchronous, remote, audiovisual communication between patients and health professionals, are being used in several countries to organize Primary Health Care (PHC) responses during the pandemic<sup>1212 Mann DM, Chen J, Chunara R, et al. COVID-19 transforms health care through telemedicine: Evidence from the field. J Am Med Inform Assoc. 2020; 27(7):1132-5.,1313 Martínez-García M, Bal-Alvarado M, Santos Guerra F, et al. Telemedicina con telemonitorización en el seguimiento de pacientes con COVID-19. Rev Clínica Esp. 2020; 220(8):472-9.,2727 Chauhan V, Galwankar S, Arquilla B, et al. Novel Coronavirus (COVID-19): Leveraging Telemedicine to Optimize Care While Minimizing Exposures and Viral Transmission. J Emerg Trauma Shock. 2020; 13(1):20-4.

28 Rockwell K, Gilroy A. Incorporating telemedicine as part of COVID-19 outbreak response systems. Am J Manag Care. 2020; 26(4):147-8.

29 Burroughs M, Urits I, Viswanath O, et al. Benefits and shortcomings of utilizing telemedicine during the COVID-19 pandemic. Bayl Univ Med Cent Proc. 2020; 33(4):699-700.

30 Ghosh A, Gupta R, Misra A. Telemedicine for diabetes care in India during COVID19 pandemic and national lockdown period: Guidelines for physicians. Diabetes Metab Syndr Clin Res Rev. 2020; 14(4):273-6.-3131 Azizy A, Fayaz M, Agirbasli M. Do Not Forget Afghanistan in Times of COVID-19: Telemedicine and the Internet of Things to Strengthen Planetary Health Systems. OMICS J Integr Biol. 2020; 24(6):311-3.</sup>.

Although not a perfect solution to every scenario^{2929 Burroughs M, Urits I, Viswanath O, et al. Benefits and shortcomings of utilizing telemedicine during the COVID-19 pandemic. Bayl Univ Med Cent Proc. 2020; 33(4):699-700.}, telemedicine has shown invaluable potential for combating the pandemic in PHC as it allows to: a) identify cases and screen contacts, supporting early detection via existing surveillance systems; b) significantly improve screening, care coordination for COVID-19 patients^{1313 Martínez-García M, Bal-Alvarado M, Santos Guerra F, et al. Telemedicina con telemonitorización en el seguimiento de pacientes con COVID-19. Rev Clínica Esp. 2020; 220(8):472-9.,2828 Rockwell K, Gilroy A. Incorporating telemedicine as part of COVID-19 outbreak response systems. Am J Manag Care. 2020; 26(4):147-8.} through follow-up of mild and moderate cases, and referral of severe cases, especially in more vulnerable areas^{2828 Rockwell K, Gilroy A. Incorporating telemedicine as part of COVID-19 outbreak response systems. Am J Manag Care. 2020; 26(4):147-8.}; c) treat COVID-19-related urgencies^{1212 Mann DM, Chen J, Chunara R, et al. COVID-19 transforms health care through telemedicine: Evidence from the field. J Am Med Inform Assoc. 2020; 27(7):1132-5.}; d) improve access to regular services, meeting the continuing care needs of non-COVID patients with other comorbidities (chronic illness, for example)^{2929 Burroughs M, Urits I, Viswanath O, et al. Benefits and shortcomings of utilizing telemedicine during the COVID-19 pandemic. Bayl Univ Med Cent Proc. 2020; 33(4):699-700.,3030 Ghosh A, Gupta R, Misra A. Telemedicine for diabetes care in India during COVID19 pandemic and national lockdown period: Guidelines for physicians. Diabetes Metab Syndr Clin Res Rev. 2020; 14(4):273-6.}; e) protect high-risk patients (older adults and those with comorbidities) by reducing their exposure in health units that can receive people with acute COVID-19 infection^{2727 Chauhan V, Galwankar S, Arquilla B, et al. Novel Coronavirus (COVID-19): Leveraging Telemedicine to Optimize Care While Minimizing Exposures and Viral Transmission. J Emerg Trauma Shock. 2020; 13(1):20-4.}; f) actively protect health professionals by reducing interactions between patient and care provider, minimizing the risk of COVID-19 transmission between infected individuals^{2727 Chauhan V, Galwankar S, Arquilla B, et al. Novel Coronavirus (COVID-19): Leveraging Telemedicine to Optimize Care While Minimizing Exposures and Viral Transmission. J Emerg Trauma Shock. 2020; 13(1):20-4.,3131 Azizy A, Fayaz M, Agirbasli M. Do Not Forget Afghanistan in Times of COVID-19: Telemedicine and the Internet of Things to Strengthen Planetary Health Systems. OMICS J Integr Biol. 2020; 24(6):311-3.}; g) avoid overcrowding in health units and reduce the risk of transmission by reducing face-to-face appointments^{2929 Burroughs M, Urits I, Viswanath O, et al. Benefits and shortcomings of utilizing telemedicine during the COVID-19 pandemic. Bayl Univ Med Cent Proc. 2020; 33(4):699-700.,3030 Ghosh A, Gupta R, Misra A. Telemedicine for diabetes care in India during COVID19 pandemic and national lockdown period: Guidelines for physicians. Diabetes Metab Syndr Clin Res Rev. 2020; 14(4):273-6.}, among others.

Brazil developed, via the Unified Health System (SUS), several initiatives based on telehealth and telemedicine to improve its response to COVID-19, both in the Ministry of Health and several state and municipal health departments^{2626 Caetano R, Silva AB, Guedes ACCM, et al. Desafios e oportunidades para telessaúde em tempos da pandemia pela COVID-19: uma reflexão sobre os espaços e iniciativas no contexto brasileiro. Cad. Saúde Pública. 2020; 36(5):e00088920.}. Law no. 696/2020 of April 15, 2020^{3232 Brasil. Lei nº 13.989, de 15 de abril de 2020. Dispõe sobre o uso da telemedicina durante a crise causada pelo coronavírus (SARS-CoV-2). Diário Oficial da União 2020. 16 Abr 2020.} innovated telemedicine by authorizing, for the duration of the pandemic, the use of telemedicine in different health-related areas in Brazil, including remote consultation.

This innovation, however, emerges amidst a bleak outlook of Brazil’s weak response to COVID-19^{3333 Sachs JD, Abdool Karim S, Aknin L, et al. Lancet COVID-19 Commission Statement on the occasion of the 75th session of the UN General Assembly. The Lancet. 2020; 396(10257):1102-24.}, characterized by the lack of articulated and coordinated actions; science denialism; simplification of the pandemic and its impacts; the promotion of treatments devoid of scientific evidence; the refusal of some segments to implement internationally recommended non-pharmacological interventions, among others<sup>3333 Sachs JD, Abdool Karim S, Aknin L, et al. Lancet COVID-19 Commission Statement on the occasion of the 75th session of the UN General Assembly. The Lancet. 2020; 396(10257):1102-24.

34 Lasco G. Medical populism and the COVID-19 pandemic. Glob Public Health. 2020; 15(10):1417-29.

35 Ferigato S, Fernandez M, Amorim M, et al. The Brazilian Government’s mistakes in responding to the COVID-19 pandemic. The Lancet. 2020; 396(10263):1636.-3636 Calheta B, Fontes B, Biagio D, et al. Boletim N° 06 Direitos na pandemia mapeamento e análise das normas jurídicas de resposta à COVID-19 no Brasil. Lockdown à brasileira. São Paulo: CEPEDISA; CONECTAS Direitos Humanos; 2020. (Boletim Direitos na pandemia).</sup>. On August 28, 2021, Brazil ranked third among the countries with the most cases, 20,570,891, and second in mortality, with 574,527 deaths (OMS. WHO Coronavirus - COVID-19 - Dashboard. https://covid19.who.int).

The municipality of Vitória in Espírito Santo, Brazil, pioneered the implementation of digital health with the Bem Estar Network (RBE), a health management software developed by municipal employees from the Undersecretariat for Information Technology (Sub-TI). Since 2009, RBE has been connecting the municipal health network - Basic Health Units (UBS), emergency care, clinical analysis laboratories, pharmacies, dental offices, specialty centers and reference centers - into a single system.

Among the strategies for combating COVID-19, the Municipal Health Department (Semus) of Vitória implemented telemedicine in March 2020 through emergency number 156, aiming to ensure the population’s access to health services and facilitate population isolation and optimization of face-to-face care infrastructure for priority cases^{3737 Vitória. Secretaria Municipal de Saúde. Nota Técnica No 0007/2020, de 24 de março de 2020. Orientações aos profissionais da Rede Municipal de Saúde de Vitória, acerca do fluxo dos atendimentos na modalidade Telemedicina através da Central 156, em detrimento ao Enfrentamento da Situação de Emergência em Saúde Pública decorrente de Pandemia em razão de doença infecciosa viral respiratória - COVID-19. Vitória: Secretaria Municipal de Saúde de Vitória; 2020.}. The strategy was regulated through Technical Note no. 0007/2020 of March 24, 2020^{3737 Vitória. Secretaria Municipal de Saúde. Nota Técnica No 0007/2020, de 24 de março de 2020. Orientações aos profissionais da Rede Municipal de Saúde de Vitória, acerca do fluxo dos atendimentos na modalidade Telemedicina através da Central 156, em detrimento ao Enfrentamento da Situação de Emergência em Saúde Pública decorrente de Pandemia em razão de doença infecciosa viral respiratória - COVID-19. Vitória: Secretaria Municipal de Saúde de Vitória; 2020.}.

Hence, this article analyzes telemedicine care in Vitória from April 2020 to March 2021 and discusses aspects of the experience to support reflections on the potentialities and challenges emerging in the fight against COVID-19.

Methods

This case study draws on Thiede et al.’s^{3838 Thiede M, Akweongo P, Di Mclntyre. Explorando as Dimensões do Acesso. In: Di Mclntyre, Mooney G, organizadores. Aspectos Econômicos da Equidade em Saúde. Rio de Janeiro: Editora Fiocruz; 2014. p. 137-61.} dimensions of access, on the guidelines for digital health, telehealth and telemedicine proposed by the WHO and the Pan American Health Organization (PAHO)^{1515 World Health Organization. Monitoring and evaluating digital health interventions: a practical guide to conducting research and assessment. Geneva: World Health Organization; 2016.,1717 Organização Mundial da Saúde. 51º Consejo Directivo 63ª Sesión del Comité Regional de la OMS para las Américas: Estrategia y plan de acción sobre eSalud. Geneva: OPS; OMS; 2011.,1818 World Health Organization. The Fifty-eighth World Health Assembly. WHA58.28 eHealth. Geneva: World Health Organization; 2005.,2121 World Health Organization. Proyecto de estrategia mundial sobre salud digital 2020-2025. Geneva: WHO; 2020. [acesso em 2021 abr 3]. Disponível em: https://cdn.who.int/media/docs/default-source/documents/gs4dhdaa2a9f352b0445bafbc79ca799dce4d_02adc66d-800b-4eb5-82d4-f0bc778a5a2c.pdf?sfvrsn=f112ede5_68.
https://cdn.who.int/media/docs/default-s... ,2323 Organização Pan-Americana da Saúde. Saúde Digital: Uma estratégia para manter a assistência à saúde de pessoas que vivem com doenças não transmissíveis durante a pandemia de COVID-19. Washington, DC: OPAS; 2020. [acesso em 2021 fev 3]. Disponível em: https://iris.paho.org/handle/10665.2/52576.
https://iris.paho.org/handle/10665.2/525... ,3939 Organización Panamericana de la Salud. Marco de Implementación de un Servicio de Telemedicina. Washington, DC: OPS; 2016.}, and on similar studies developed in other countries<sup>1212 Mann DM, Chen J, Chunara R, et al. COVID-19 transforms health care through telemedicine: Evidence from the field. J Am Med Inform Assoc. 2020; 27(7):1132-5.,1313 Martínez-García M, Bal-Alvarado M, Santos Guerra F, et al. Telemedicina con telemonitorización en el seguimiento de pacientes con COVID-19. Rev Clínica Esp. 2020; 220(8):472-9.,2727 Chauhan V, Galwankar S, Arquilla B, et al. Novel Coronavirus (COVID-19): Leveraging Telemedicine to Optimize Care While Minimizing Exposures and Viral Transmission. J Emerg Trauma Shock. 2020; 13(1):20-4.

28 Rockwell K, Gilroy A. Incorporating telemedicine as part of COVID-19 outbreak response systems. Am J Manag Care. 2020; 26(4):147-8.

29 Burroughs M, Urits I, Viswanath O, et al. Benefits and shortcomings of utilizing telemedicine during the COVID-19 pandemic. Bayl Univ Med Cent Proc. 2020; 33(4):699-700.

30 Ghosh A, Gupta R, Misra A. Telemedicine for diabetes care in India during COVID19 pandemic and national lockdown period: Guidelines for physicians. Diabetes Metab Syndr Clin Res Rev. 2020; 14(4):273-6.-3131 Azizy A, Fayaz M, Agirbasli M. Do Not Forget Afghanistan in Times of COVID-19: Telemedicine and the Internet of Things to Strengthen Planetary Health Systems. OMICS J Integr Biol. 2020; 24(6):311-3.</sup>. Based on these documentary sources and secondary data, we sought to examine the telemedicine care process implemented in the UBS of the municipality of Vitória to combat COVID-19. The city of Vitória was chosen due to its pioneer implementation of RBE and database availability when the research was approved by Semus. On-site work was replaced by online meetings.

Data was collected from records regarding telemedicine care offered to the population of Vitória through emergency number 156. The variables analyzed comprised: date of care; time of care; type of professional; age; gender; ethnicity/color; patient’s UBS of origin; code and description according to the International Classification of Diseases (ICD-10); risk classification; classification, referrals, and documents generated in the last follow-up.

The study included all 29 UBS and considered the period from April 1, 2020, to March 31, 20200, using data from RBE’s report ‘Telemedicine - Performed Care’^{4040 Vitória. Secretaria Municipal de Saúde. Rede Bem-estar. Relatório Telemedicina - Atendimentos Realizados. Vitória: SMSV; 2021.}. We also used official documents about the process of telemedicine implementation in the municipality in 2020^{3232 Brasil. Lei nº 13.989, de 15 de abril de 2020. Dispõe sobre o uso da telemedicina durante a crise causada pelo coronavírus (SARS-CoV-2). Diário Oficial da União 2020. 16 Abr 2020.,3737 Vitória. Secretaria Municipal de Saúde. Nota Técnica No 0007/2020, de 24 de março de 2020. Orientações aos profissionais da Rede Municipal de Saúde de Vitória, acerca do fluxo dos atendimentos na modalidade Telemedicina através da Central 156, em detrimento ao Enfrentamento da Situação de Emergência em Saúde Pública decorrente de Pandemia em razão de doença infecciosa viral respiratória - COVID-19. Vitória: Secretaria Municipal de Saúde de Vitória; 2020.,4141 Vitória. Prefeitura, Secretaria Municipal de Saúde, Gerência de Atenção à Saúde. Fluxograma dos atendimentos na modalidade telemedicina através da central 156. Vitória, Espírito Santo, Brasil, 2020. Vitória: Secretaria Municipal de Saúde de Vitória; 2020.,4242 Vitória. Secretaria Municipal de Saúde. Guia prático: orientação na condução do atendimento por telemedicina via 156. Vitória: Secretaria Municipal de Saúde de Vitória; 2020. p. 36.}, consultations with the Sub-IT, discussions in virtual workshops (by Zoom, Meet or WhatsApp) and e-mails exchanged with the management bodies or those indicated as having greater knowledge of the process.

Number of consultations per 10,000 inhabitants was calculated for the municipality and health regions using as numerator the quarterly averages of telemedicine care according to the user’s UBS of origin and as denominator the number of inhabitants living in neighborhoods/sectors for 2020 according to the 2010 census projections by the Brazilian Institute of Geography and Statistics (IBGE)^{4343 Instituto Brasileiro de Geografia e Estatística. População 2019, segundo projeções do censo do IBGE 2011. Rio de Janeiro: IBGE; 2019. [acesso em 2021 jan 30]. Disponível em: https://www.ibge.gov.br/estatisticas/sociais/populacao/22827-censo-2020-censo4.html?=&t=series-historicas.
https://www.ibge.gov.br/estatisticas/soc...} . Thus, any random fluctuations that may occur in health regions with small denominators, such as possible reporting errors, were minimized. In calculating COVID-19 consultations per 10,000 inhabitants, the numerator was the quarterly averages of care classified by the ICD-10 codes B342 (Coronavirus infection, unspecified site) and B972 (Coronavirus as the cause of diseases classified to other chapters), and as denominator the number of inhabitants by neighborhoods/sectors for 2019, according to IBGE 2010 census projections. Descriptive analysis was performed based on the selected variables summarized in tables and graphs developed in Microsoft Excel® 2020 and Microsoft Word® 2020 programs.

Results were analyzed based on WHO’s and PAHO’s guidelines on digital health, telehealth and telemedicine^{1515 World Health Organization. Monitoring and evaluating digital health interventions: a practical guide to conducting research and assessment. Geneva: World Health Organization; 2016.,1818 World Health Organization. The Fifty-eighth World Health Assembly. WHA58.28 eHealth. Geneva: World Health Organization; 2005.,2121 World Health Organization. Proyecto de estrategia mundial sobre salud digital 2020-2025. Geneva: WHO; 2020. [acesso em 2021 abr 3]. Disponível em: https://cdn.who.int/media/docs/default-source/documents/gs4dhdaa2a9f352b0445bafbc79ca799dce4d_02adc66d-800b-4eb5-82d4-f0bc778a5a2c.pdf?sfvrsn=f112ede5_68.
https://cdn.who.int/media/docs/default-s... ,2323 Organização Pan-Americana da Saúde. Saúde Digital: Uma estratégia para manter a assistência à saúde de pessoas que vivem com doenças não transmissíveis durante a pandemia de COVID-19. Washington, DC: OPAS; 2020. [acesso em 2021 fev 3]. Disponível em: https://iris.paho.org/handle/10665.2/52576.
https://iris.paho.org/handle/10665.2/525... ,3939 Organización Panamericana de la Salud. Marco de Implementación de un Servicio de Telemedicina. Washington, DC: OPS; 2016.} (as described in the introduction); in similar studies developed in other countries<sup>1212 Mann DM, Chen J, Chunara R, et al. COVID-19 transforms health care through telemedicine: Evidence from the field. J Am Med Inform Assoc. 2020; 27(7):1132-5.,1313 Martínez-García M, Bal-Alvarado M, Santos Guerra F, et al. Telemedicina con telemonitorización en el seguimiento de pacientes con COVID-19. Rev Clínica Esp. 2020; 220(8):472-9.,2727 Chauhan V, Galwankar S, Arquilla B, et al. Novel Coronavirus (COVID-19): Leveraging Telemedicine to Optimize Care While Minimizing Exposures and Viral Transmission. J Emerg Trauma Shock. 2020; 13(1):20-4.

28 Rockwell K, Gilroy A. Incorporating telemedicine as part of COVID-19 outbreak response systems. Am J Manag Care. 2020; 26(4):147-8.

29 Burroughs M, Urits I, Viswanath O, et al. Benefits and shortcomings of utilizing telemedicine during the COVID-19 pandemic. Bayl Univ Med Cent Proc. 2020; 33(4):699-700.

30 Ghosh A, Gupta R, Misra A. Telemedicine for diabetes care in India during COVID19 pandemic and national lockdown period: Guidelines for physicians. Diabetes Metab Syndr Clin Res Rev. 2020; 14(4):273-6.-3131 Azizy A, Fayaz M, Agirbasli M. Do Not Forget Afghanistan in Times of COVID-19: Telemedicine and the Internet of Things to Strengthen Planetary Health Systems. OMICS J Integr Biol. 2020; 24(6):311-3.</sup>; and in the theoretical framework on access^{3838 Thiede M, Akweongo P, Di Mclntyre. Explorando as Dimensões do Acesso. In: Di Mclntyre, Mooney G, organizadores. Aspectos Econômicos da Equidade em Saúde. Rio de Janeiro: Editora Fiocruz; 2014. p. 137-61.}. Thiede et al. consider the multidimensionality of access through three dimensions: availability, financial viability and acceptability. Factors that influence access are systematically grouped in each dimension at different levels (health system, individual or family).

The three dimensions are interdependent and conceptually separable, as each one is delimited and concentrates factors strongly associated with each other. Thiede et al. define access as the ‘degree of adequacy’ between the health system and its users, that is, access takes place in the communicative interaction between the health system factors and the individual or family factors in each dimension^{3838 Thiede M, Akweongo P, Di Mclntyre. Explorando as Dimensões do Acesso. In: Di Mclntyre, Mooney G, organizadores. Aspectos Econômicos da Equidade em Saúde. Rio de Janeiro: Editora Fiocruz; 2014. p. 137-61.}.

Availability includes adequate health services available to users, at the place and time required by users. It encompass the relation between the location of health services and their users (distance); transportation options; the degree of schedule adequacy; the type, quantity and quality of health services provided; the composition of each team, availability of equipment and supplies^{3838 Thiede M, Akweongo P, Di Mclntyre. Explorando as Dimensões do Acesso. In: Di Mclntyre, Mooney G, organizadores. Aspectos Econômicos da Equidade em Saúde. Rio de Janeiro: Editora Fiocruz; 2014. p. 137-61.}.

Financial viability refers to how well the cost of using health care services matches the individuals’ ability to pay. A key point of this dimension is to know how the costs of health services and the families’ ability to pay interact, to avoid generating social costs with catastrophic effects on the most vulnerable population groups^{3838 Thiede M, Akweongo P, Di Mclntyre. Explorando as Dimensões do Acesso. In: Di Mclntyre, Mooney G, organizadores. Aspectos Econômicos da Equidade em Saúde. Rio de Janeiro: Editora Fiocruz; 2014. p. 137-61.}.

Acceptability, understood as “the social and cultural distance between health services and their users”^{4444 Gilson L. Aceitabilidade, Confiança e Equidade. In: Di Mclntyre, Mooney G, organizadores. Aspectos Econômicos da Equidade em Saúde. Rio de Janeiro: Editora Fiocruz; 2014. p. 163-90.(163)}, consists of three components: the match between users’ and professionals’ beliefs about health; the commitment and dialogue between provider and user; and the influence of organizational arrangements on users’ decisions about whether or not to seek care and where. Hence, improvements in accessibility depend on the communicative interaction between the actors involved^{3838 Thiede M, Akweongo P, Di Mclntyre. Explorando as Dimensões do Acesso. In: Di Mclntyre, Mooney G, organizadores. Aspectos Econômicos da Equidade em Saúde. Rio de Janeiro: Editora Fiocruz; 2014. p. 137-61.}. This dynamic process represents the potential to interact and make adjustments for the better operation of health systems, besides being the guiding axis for promoting equitable access^{3838 Thiede M, Akweongo P, Di Mclntyre. Explorando as Dimensões do Acesso. In: Di Mclntyre, Mooney G, organizadores. Aspectos Econômicos da Equidade em Saúde. Rio de Janeiro: Editora Fiocruz; 2014. p. 137-61.}.

Study results are limited to the municipality of Vitória, and the analyses consider consultations made through emergency number 156.

This study is part of a research funded by Inova-Fiocruz and was approved by the Research Ethics Committee of the National School of Public Health Sergio Arouca/Ensp-Fiocruz (CAAE 28140619.0.1001.5240) and by the Technical Research Committee of the City Hall and Semus Saúde MV/Semus.

Results

Context

Vitória, along with 19 other municipalities makes up the Metropolitan Health Region of the state of Espírito Santo (ES), is the capital and the fourth most populous city of the state’s 78 municipalities, with 365,855 inhabitants and a population density of 3,766.92 inhabitants/km (IBGE, 2020 https://cidades.ibge.gov.br/brasil/es/vitoria/panorama). Health care organization encompasses six health regions (Santo Antônio, Maruípe, Forte de São João, Continental and Centro), 29 Health Territories/UBS (TS/UBS), and 79 neighborhoods.

The city’s Municipal Health Department (Semus), by means of Technical Note No. 0007/2020, of March 24, 2020^{3737 Vitória. Secretaria Municipal de Saúde. Nota Técnica No 0007/2020, de 24 de março de 2020. Orientações aos profissionais da Rede Municipal de Saúde de Vitória, acerca do fluxo dos atendimentos na modalidade Telemedicina através da Central 156, em detrimento ao Enfrentamento da Situação de Emergência em Saúde Pública decorrente de Pandemia em razão de doença infecciosa viral respiratória - COVID-19. Vitória: Secretaria Municipal de Saúde de Vitória; 2020.}, implemented telemedicine via emergency number 156 as one strategy to combat COVID-19. Teleconsultation, telemedicine, teleorientation and telemonitoring services were made available aiming to expand the population’s access to health care for risk stratification, early identification and proper referral of severe cases^{3737 Vitória. Secretaria Municipal de Saúde. Nota Técnica No 0007/2020, de 24 de março de 2020. Orientações aos profissionais da Rede Municipal de Saúde de Vitória, acerca do fluxo dos atendimentos na modalidade Telemedicina através da Central 156, em detrimento ao Enfrentamento da Situação de Emergência em Saúde Pública decorrente de Pandemia em razão de doença infecciosa viral respiratória - COVID-19. Vitória: Secretaria Municipal de Saúde de Vitória; 2020.}.

Emergency number 156 provides information to guide users and allow access to safe and qualified medical evaluation^{3737 Vitória. Secretaria Municipal de Saúde. Nota Técnica No 0007/2020, de 24 de março de 2020. Orientações aos profissionais da Rede Municipal de Saúde de Vitória, acerca do fluxo dos atendimentos na modalidade Telemedicina através da Central 156, em detrimento ao Enfrentamento da Situação de Emergência em Saúde Pública decorrente de Pandemia em razão de doença infecciosa viral respiratória - COVID-19. Vitória: Secretaria Municipal de Saúde de Vitória; 2020.,4141 Vitória. Prefeitura, Secretaria Municipal de Saúde, Gerência de Atenção à Saúde. Fluxograma dos atendimentos na modalidade telemedicina através da central 156. Vitória, Espírito Santo, Brasil, 2020. Vitória: Secretaria Municipal de Saúde de Vitória; 2020.}. Care (figure 1) is initiated by a nurse aided by a specific checklist with closed and self-reported questions answered by the user to identify possible flu-like syndromes, epidemiological linkage, general and specific guidelines, among others. In case of a clinical demand, the call is transferred for medical evaluation. Professionals can also transfer calls for clinical evaluation by physicians.

In the period analyzed, telemedicine clinical care was performed exclusively by physicians in home office. To meet the demand, the strategy included different expert physicians from the entire health network. In April 2020, RBE created the ‘Escritório na Casa’ (Home Office) to register all calls made to emergency number 156. Within RBE, physicians who already worked at a UBS used the same user profile to join the system. Specialized care physicians were virtually allocated within RBE, mostly at UBS Forte São João.

All telemedicine calls were entered into the RBE with procedure codes 03.01.01.007-2 (Consultation in Specialized Care) and 03.01.01.TELE (Teleconsultation) and the respective ICD-10 code. In the electronic health record, physicians could fill out one or more of the following forms: record of respiratory symptom care; notification of suspected COVID-19 case; request for RT-PCR COVID-19 testing; issuance of health certificates, reports, prescriptions, and test requisitions; sending documents with digital signature by e-mail; referral for on-site evaluation at the UBS or Emergency Services (PAs).

To answer the transferred calls, physicians used their personal phones on which they registered the telephone line ‘Fala Vitória’ 156 service. Another resource to ensure the virtual work environment was the availability of a computer connected to the internet and with remote access to the RBE. Each physician used their personal computer and had the support of a technical team when necessary for installation and remote access to the RBE.

Telemedicine care

From April 2020 to March 2021, telemedicine served 15,548 users (table 1), of which 64% were women (9,953) and 36% men (5,595). Regarding age group, most patients were 30-39 years old (19.5%), followed by 40-49 years old (17.8%), with mean age of 41 years. As for ethnicity/color, 38.6% of the users declared themselves white and 33.5% Brown. Black and Indigenous users totaled only 7.7% and 0.1%, respectively. A total of 3,084 user records lacked information on the ethnicity/color variable, with better completion in the last two quarters analyzed.

In the period analyzed, emergency number 156 registered 21,481 consultations (table 2) distributed among 15,548 users. Of these, 55.2% correspond to users with one consultation (11,862) and 44.8% (9,619) to 3,686 users (24%) with more than one consultation. Clinicians and pediatricians performed 64% of the consultations. Most telemedicine users and services according to the UBS of origin was concentrated in the Continental and Maruípe health regions; the Centro and São Pedro regions registered the lowest number (tables 1 and 2). The municipality registered the highest number of consultations (7,216) from April to June 2020, and the lowest number from October to December 2020 (3,936 - tabela 2). June 2020 showed the highest number of telemedicine consultations (3,074) and November, the lowest (651).

Of the 21,481 consultations performed, 56% (11,946) were classified as Coronavirus infection, unspecified site (B342) and Coronavirus as the cause of diseases classified to other chapters (B972 - table 3)

Risk classification occurred without warning signs in 76% of these consultations (9,081) and 20.3% showed warning signs (2,427). Severity signs were indicated in 33 consultations (0.3%). Essential hypertension (primary - I10) was the second cause for consultations (2.3%) A total of 1,444 records did not inform the ICD-10 code (6.7%). The Continental and Maruípe health regions concentrated the highest number of appointments for causes B342 and B972 with 31.2% and 24.4%, respectively.

For these causes, 34.6% of the calls (4,133) referred to uses with one or more consultations; in these, classification of the last monitoring reported was ‘better’ (34.5%). However, 1,493 records failed to fill this variable (36,1%). The most frequent referral in the last monitoring was ‘maintain follow-up in home isolation’ (32.7%), and 1,537 records (37.2%) lacked information on this variable. The most frequently generated documents in the last monitoring were prescriptions and laboratory test requests for COVID-19 (34.6%). However, in almost 21% (847) this variable was missing information.

In the municipality, the number of telemedicine consultations per 10,000 inhabitants considering all causes ranged from 35.86 consultations per 10,000 inhabitants between October and December 2020, to 65.75 between April and June 2020 (table 4)

Differences between health regions ranged from 15.40 telemedicine consultations per 10,000 inhabitants in São Pedro from October to December 2020 to 114.28 in Santo Antônio from July to September 2020. In Vitória, the number of telemedicine consultations per 10,000 inhabitants considering only causes B342 and B972 ranged from 22.54 consultations per 10,000 inhabitants between October to December 2020 to 31.96 between April to June 2020. Between health regions, variation was 10.71 telemedicine consultations per 10,000 inhabitants in São Pedro from October to December 2020 and 47.66 in Maruípe from April to June 2020.

Discussion

Our findings reflect the transformative impact COVID-19 had on telemedicine-oriented health care^{1212 Mann DM, Chen J, Chunara R, et al. COVID-19 transforms health care through telemedicine: Evidence from the field. J Am Med Inform Assoc. 2020; 27(7):1132-5.,1414 Pérez Sust P, Solans O, Fajardo JC, et al. Turning the Crisis Into an Opportunity: Digital Health Strategies Deployed During the COVID-19 Outbreak. JMIR Public Health Surveill. 2020; 6(2):e19106.,2525 Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health. 2020; 20(1):1193.,2828 Rockwell K, Gilroy A. Incorporating telemedicine as part of COVID-19 outbreak response systems. Am J Manag Care. 2020; 26(4):147-8.} as part of the first-line response systems^{4545 Vidal-Alaball J, Acosta-Roja R, Pastor Hernández N, et al. Telemedicine in the face of the COVID-19 pandemic. Aten Primaria. 2020; 52(6):418-22.} to the pandemic in Vitória, Espírito Santo, Brazil. As in other experiences, expansion of these services was limited to the COVID-19 scenario and not to their broader use within the health care system^{1010 Sarbadhikari S, Sarbadhikari S. The global experience of digital health interventions in COVID-19 management. Indian J Public Health. 2020; 64(6):117.,1212 Mann DM, Chen J, Chunara R, et al. COVID-19 transforms health care through telemedicine: Evidence from the field. J Am Med Inform Assoc. 2020; 27(7):1132-5.,2525 Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health. 2020; 20(1):1193.}, despite its feasibility. Telemedicine and more specifically teleconsultation were the main tools used by the municipality to maintain the secure availability of services, enabling diagnosis, screening, treatment prescription and follow-up of confirmed and suspected COVID-19 cases, among others^{1010 Sarbadhikari S, Sarbadhikari S. The global experience of digital health interventions in COVID-19 management. Indian J Public Health. 2020; 64(6):117.,2525 Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health. 2020; 20(1):1193.,2626 Caetano R, Silva AB, Guedes ACCM, et al. Desafios e oportunidades para telessaúde em tempos da pandemia pela COVID-19: uma reflexão sobre os espaços e iniciativas no contexto brasileiro. Cad. Saúde Pública. 2020; 36(5):e00088920.}.

To ensure the necessary elements for ‘availability’^{3838 Thiede M, Akweongo P, Di Mclntyre. Explorando as Dimensões do Acesso. In: Di Mclntyre, Mooney G, organizadores. Aspectos Econômicos da Equidade em Saúde. Rio de Janeiro: Editora Fiocruz; 2014. p. 137-61.}, the municipality designed a strategy to mobilize a team of physicians from different areas of the network for home office care, between 8 a.m. and 10 p.m. This allowed to adapt service provision to the pandemic context; make care schedules more flexible; ensure that services would be provided by qualified medical personnel; include in the care scale those professionals in the risk group for COVID-19; maintain the necessary staff in the UBS to perform on-site care for cases that required it, including the continuous care of non-COVID patients and protect UBS professionals and users, among others.

Although the distance between health services and users in eHealth does not constitute a barrier, other key elements are needed to ensure availability, which may or may not be required when care is performed face-to-face^{1111 Murray CJL, Alamro NMS, Hwang H, et al. Digital public health and COVID-19. Lancet Public Health. 2020; 5(9):e469-70.,4646 Organización Panamericana de la Salud. Ocho principios rectores de la transformación digital del sector de la salud. Un llamado a la acción panamericana. Washington, DC: OPS; 2021.}: the physicians’ digital literacy^{1111 Murray CJL, Alamro NMS, Hwang H, et al. Digital public health and COVID-19. Lancet Public Health. 2020; 5(9):e469-70.,2121 World Health Organization. Proyecto de estrategia mundial sobre salud digital 2020-2025. Geneva: WHO; 2020. [acesso em 2021 abr 3]. Disponível em: https://cdn.who.int/media/docs/default-source/documents/gs4dhdaa2a9f352b0445bafbc79ca799dce4d_02adc66d-800b-4eb5-82d4-f0bc778a5a2c.pdf?sfvrsn=f112ede5_68.
https://cdn.who.int/media/docs/default-s... ,4646 Organización Panamericana de la Salud. Ocho principios rectores de la transformación digital del sector de la salud. Un llamado a la acción panamericana. Washington, DC: OPS; 2021.} to fill RBE data and perform care; have the necessary technological resources (telephone, computer, internet connection); staff training to improve its communication skills via phone; coordination between primary care and other user referral services; promotion of the emergency number 156 among vulnerable populations, among others.

Studies show that telemedicine interventions in PHC are low cost, feasible and accessible to health professionals and users^{4747 Bashshur RL, Howell JD, Krupinski EA, et al. The Empirical Foundations of Telemedicine Interventions in Primary Care. Telemed E-Health. 2016; 22(5):342-75.}. They can generally result in cost savings and easier access to health-related information in real time (as in the case of the municipality of Vitória)^{4545 Vidal-Alaball J, Acosta-Roja R, Pastor Hernández N, et al. Telemedicine in the face of the COVID-19 pandemic. Aten Primaria. 2020; 52(6):418-22.,4747 Bashshur RL, Howell JD, Krupinski EA, et al. The Empirical Foundations of Telemedicine Interventions in Primary Care. Telemed E-Health. 2016; 22(5):342-75.}. Personalized telephone care of cases and subsequent follow-up allows to contain coronavirus dissemination, as well as a better use of human resources, especially in areas with scarce infrastructure or under circumstances of high stress for the health care team^{2727 Chauhan V, Galwankar S, Arquilla B, et al. Novel Coronavirus (COVID-19): Leveraging Telemedicine to Optimize Care While Minimizing Exposures and Viral Transmission. J Emerg Trauma Shock. 2020; 13(1):20-4.}. Besides, it reduces input consumption due to the reduced need for personal protective equipment, which can represent substantial savings when considered on a large scale^{2727 Chauhan V, Galwankar S, Arquilla B, et al. Novel Coronavirus (COVID-19): Leveraging Telemedicine to Optimize Care While Minimizing Exposures and Viral Transmission. J Emerg Trauma Shock. 2020; 13(1):20-4.}.

Other aspects regarding ‘financial viability’^{3838 Thiede M, Akweongo P, Di Mclntyre. Explorando as Dimensões do Acesso. In: Di Mclntyre, Mooney G, organizadores. Aspectos Econômicos da Equidade em Saúde. Rio de Janeiro: Editora Fiocruz; 2014. p. 137-61.} in telemedicine includes possible improvements to health care accessibility, saving time and money for both users (specially those living in remote and less favored social territories) and the health system; possible inter-consultation and sending diagnosis via internet to the assistant physician^{2626 Caetano R, Silva AB, Guedes ACCM, et al. Desafios e oportunidades para telessaúde em tempos da pandemia pela COVID-19: uma reflexão sobre os espaços e iniciativas no contexto brasileiro. Cad. Saúde Pública. 2020; 36(5):e00088920.,4848 Galván P, Rivas R, Ortellado J, et al. Aplicación de tecnologías disruptivas en telemedicina para la cobertura universal de servicios de salud. Rev Salud Pública Parag. 2020; 10(1):52-8.,4949 Chá Ghiglia MM. Telemedicina: su rol en las organizaciones de salud. Rev Med. Urug. 2020 [acesso em 2021 jun 21]; 36(1). Disponível em: https://revista.rmu.org.uy/ojsrmu311/index.php/rmu/article/view/647/658.
https://revista.rmu.org.uy/ojsrmu311/ind...} .

As in face-to-face care, user ‘acceptability’ is essential to ensure access to telemedicine; but this dimension remains largely neglected^{4444 Gilson L. Aceitabilidade, Confiança e Equidade. In: Di Mclntyre, Mooney G, organizadores. Aspectos Econômicos da Equidade em Saúde. Rio de Janeiro: Editora Fiocruz; 2014. p. 163-90.}. Acceptability and trust barriers can influence the behavior and interaction of health care users and providers, disproportionately affecting socially disadvantaged groups with lower digital literacy and less access to ICTs^{1111 Murray CJL, Alamro NMS, Hwang H, et al. Digital public health and COVID-19. Lancet Public Health. 2020; 5(9):e469-70.,2121 World Health Organization. Proyecto de estrategia mundial sobre salud digital 2020-2025. Geneva: WHO; 2020. [acesso em 2021 abr 3]. Disponível em: https://cdn.who.int/media/docs/default-source/documents/gs4dhdaa2a9f352b0445bafbc79ca799dce4d_02adc66d-800b-4eb5-82d4-f0bc778a5a2c.pdf?sfvrsn=f112ede5_68.
https://cdn.who.int/media/docs/default-s... ,3838 Thiede M, Akweongo P, Di Mclntyre. Explorando as Dimensões do Acesso. In: Di Mclntyre, Mooney G, organizadores. Aspectos Econômicos da Equidade em Saúde. Rio de Janeiro: Editora Fiocruz; 2014. p. 137-61.,4444 Gilson L. Aceitabilidade, Confiança e Equidade. In: Di Mclntyre, Mooney G, organizadores. Aspectos Econômicos da Equidade em Saúde. Rio de Janeiro: Editora Fiocruz; 2014. p. 163-90.,4646 Organización Panamericana de la Salud. Ocho principios rectores de la transformación digital del sector de la salud. Un llamado a la acción panamericana. Washington, DC: OPS; 2021.}. Vitória has a user satisfaction evaluation system, but there is no possibility of obtaining data by type of care. Evaluations made by telemedicine users are included in the total responses sent, which hindered extracting RBE data on telemedicine user acceptability.

Health information systems play a key role in data production on knowledge, attitudes and behaviors of health care professionals and users, as well as on the other dimensions of access in the face-to-face care and telemedicine^{5050 Davies SC, Audi H, Cuddihy M. Leveraging data and new digital tools to prepare for the next pandemic. The Lancet. 2021; 397(10282):1349-50.}. Hence, integrating different data sources is fundamental^{1212 Mann DM, Chen J, Chunara R, et al. COVID-19 transforms health care through telemedicine: Evidence from the field. J Am Med Inform Assoc. 2020; 27(7):1132-5.,1414 Pérez Sust P, Solans O, Fajardo JC, et al. Turning the Crisis Into an Opportunity: Digital Health Strategies Deployed During the COVID-19 Outbreak. JMIR Public Health Surveill. 2020; 6(2):e19106.}, as is promoting a more comprehensive data ecosystem where information is included to monitor and evaluate care access and its different dimensions^{5050 Davies SC, Audi H, Cuddihy M. Leveraging data and new digital tools to prepare for the next pandemic. The Lancet. 2021; 397(10282):1349-50.}. Despite some advances, the integration of the e-SUS PHC strategy systems with the municipalities own existing systems (such as RBE in Vitória) remain a challenge in Brazil.

RBE-generated data allows to evaluate primarily the availability dimension. Financial viability can only be analyzed with proxy variables not available in RBE reports. The municipality of Vitória has real-time data and it is possible to fill in data directly into the health record. For better RBE usability, however, we must invest in a culture of systematic data quality auditing, where completeness is key. Data integration on the care provided to the same user in the different modalities is still limited. This hinders knowing the access route followed by the user after consultation at emergency number 156, as well as following up on cases that were referred to telemedicine and whose data were filled out in another form. Countries that have advanced in producing information on health accessibility via telemedicine and eHealth and their impact on the pandemic show efforts in data integration^{1414 Pérez Sust P, Solans O, Fajardo JC, et al. Turning the Crisis Into an Opportunity: Digital Health Strategies Deployed During the COVID-19 Outbreak. JMIR Public Health Surveill. 2020; 6(2):e19106.,5151 Chunara R, Zhao Y, Chen J, et al. Telemedicine and healthcare disparities: a cohort study in a large healthcare system in New York City during COVID-19. J Am Med Inform Assoc. 2021; 28(1):33-41.}.

Final considerations and challenges

Long-term inclusive digital health strategies can accelerate the implementation of effective public health responses to pandemics, as well as process changes needed for emergencies^{1111 Murray CJL, Alamro NMS, Hwang H, et al. Digital public health and COVID-19. Lancet Public Health. 2020; 5(9):e469-70.,1414 Pérez Sust P, Solans O, Fajardo JC, et al. Turning the Crisis Into an Opportunity: Digital Health Strategies Deployed During the COVID-19 Outbreak. JMIR Public Health Surveill. 2020; 6(2):e19106.,4646 Organización Panamericana de la Salud. Ocho principios rectores de la transformación digital del sector de la salud. Un llamado a la acción panamericana. Washington, DC: OPS; 2021.}. COVID-19 unveiled part of this untapped potential to some countries^{1010 Sarbadhikari S, Sarbadhikari S. The global experience of digital health interventions in COVID-19 management. Indian J Public Health. 2020; 64(6):117.,1212 Mann DM, Chen J, Chunara R, et al. COVID-19 transforms health care through telemedicine: Evidence from the field. J Am Med Inform Assoc. 2020; 27(7):1132-5.,2727 Chauhan V, Galwankar S, Arquilla B, et al. Novel Coronavirus (COVID-19): Leveraging Telemedicine to Optimize Care While Minimizing Exposures and Viral Transmission. J Emerg Trauma Shock. 2020; 13(1):20-4.,4545 Vidal-Alaball J, Acosta-Roja R, Pastor Hernández N, et al. Telemedicine in the face of the COVID-19 pandemic. Aten Primaria. 2020; 52(6):418-22.} and to several Brazilian municipalities and states^{2626 Caetano R, Silva AB, Guedes ACCM, et al. Desafios e oportunidades para telessaúde em tempos da pandemia pela COVID-19: uma reflexão sobre os espaços e iniciativas no contexto brasileiro. Cad. Saúde Pública. 2020; 36(5):e00088920.}, such as Vitória (ES), where strategies to include digital health into health care services were implemented at an unprecedented rate^{1212 Mann DM, Chen J, Chunara R, et al. COVID-19 transforms health care through telemedicine: Evidence from the field. J Am Med Inform Assoc. 2020; 27(7):1132-5.}.

However, much of this potential remains little explored^{1111 Murray CJL, Alamro NMS, Hwang H, et al. Digital public health and COVID-19. Lancet Public Health. 2020; 5(9):e469-70.}. Among the main barriers^{1010 Sarbadhikari S, Sarbadhikari S. The global experience of digital health interventions in COVID-19 management. Indian J Public Health. 2020; 64(6):117.,1111 Murray CJL, Alamro NMS, Hwang H, et al. Digital public health and COVID-19. Lancet Public Health. 2020; 5(9):e469-70.} we highlight: limited digital literacy among the population (with greater gaps for the most vulnerable) and health professionals; tendency to suppress data if deficient; limited capacity of health information systems to integrate data from multiple sources; resistance of health users and services to new ways of working; digital security and associated costs; poor internet access and access to digital technologies in disadvantaged areas; reproduction, in virtual spaces, of face-to-face care inequalities; among others. WHO’s ‘Global Strategy on Digital Health 2020-2025^’21 and PAHO’s ‘Eight Guiding Principles of Digital Transformation of the Health Sector’^{4646 Organización Panamericana de la Salud. Ocho principios rectores de la transformación digital del sector de la salud. Un llamado a la acción panamericana. Washington, DC: OPS; 2021.}, dictate the design of inclusive and sustainable public policies over time to overcome those barriers.

Among the challenges to improving health care accessibility via telemedicine and eHealth is the unraveling of obstacles and facilitators from the perspective of health professionals, managers, and users^{2525 Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health. 2020; 20(1):1193.}. Investments are needed for integration of data from various sources and its usability, and for digital inclusion of the population and health professionals. As face-to-face access inequalities are reproduced in telemedicine access^{5151 Chunara R, Zhao Y, Chen J, et al. Telemedicine and healthcare disparities: a cohort study in a large healthcare system in New York City during COVID-19. J Am Med Inform Assoc. 2021; 28(1):33-41.}, it is essential to maintain a strong relationship between the health system, health teams, and users when implementing telemedicine^{4949 Chá Ghiglia MM. Telemedicina: su rol en las organizaciones de salud. Rev Med. Urug. 2020 [acesso em 2021 jun 21]; 36(1). Disponível em: https://revista.rmu.org.uy/ojsrmu311/index.php/rmu/article/view/647/658.
https://revista.rmu.org.uy/ojsrmu311/ind...} . Although the latter is considered an innovation, both care models remain interdependent and complementary in the quest to ensure equitable access to health care.

Acknowledgments

We thank Paulo César Barbosa Fernandes, Undersecretary of Information Technology (Sub-TI) of the Municipal Health Department (Semus) in Vitória, Espírito Santo, for the support.

Referências

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