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Reactions of physicians in the state of São Paulo to the use of telemedicine during the SARS-CoV-2 pandemic: cross-sectional study

ABSTRACT BACKGROUND: Telemedicine can be a component of integrated healthcare practices and its use is not a recent phenomenon around the world. In Brazil, its more widespread use began during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, through extraordinary authorization from the Brazilian Ministry of Health. OBJECTIVES: To describe some aspects of use of teleconsultation among a sample of physicians in the state of São Paulo during the SARS-CoV-2 pandemic. DESIGN AND SETTING: Cross-sectional study based on a survey conducted by the São Paulo Medical Association (Associação Paulista de Medicina, APM) on medical practice during the SARS-CoV-2 pandemic between December 18, 2020, and January 18, 2021. RESULTS: This survey generated responses from 2,052 physicians. Of these, 981 (47.8%) reported not practicing any form of telemedicine. Among those who reported practicing telemedicine, 274 (28.4%) reported not receiving remuneration directly for the attendance provided and 225 (23.3%) reported receiving remuneration equal to what they would have received from face-to-face consultations. Regarding the professional linkage of the physicians who undertook telemedicine attendance, the majority (499; 51.8%) only attended private patients. Regarding the resources used to provide telemedicine attendance, most of the respondents used specialized digital platforms (594; 61.6%), electronic health records (592; 61.4%) and electronic prescriptions (700; 72.6%). CONCLUSION: This study demonstrates that important issues such as professional remuneration, use of electronic platforms and medical records, ensuring data protection and relationships between physicians and other stakeholders still need to be better defined, in order to achieve the desired scale and reach the outcomes defined.


INTRODUCTION
Telemedicine can be defined as provision of healthcare in which the participants are separated in time and/or space, while telehealth is of broader nature, involving all health-related telecommunications applications. 1 Telemedicine thus involves use of interactive information and telecommunications technologies, combined with computer systems, telemetry and biosensors to provide quality healthcare services that are not physically face-to-face and are outside the clinical-hospital space. It thus enhances the relationship between healthcare professionals and their patients, through eliminating geographical and time barriers. 2 On the other hand, remote consultation can be defined as care provision mediated by technologies in which professionals and patients are in different physical spaces. It covers the same characteristic steps and responsibilities as in face-to-face attendance, including subjective, objective and diagnostic assessments, therapeutic proposals, requests for complementary tests, guidance and planning of care. 3 The use of telemedicine is not a recent phenomenon: there have been reports of its use since the 1960s, but its more widespread utilization began with the development of the internet in the 1990s. 4 For example, the American health plan and health provider Kaiser Permanente reported that in 2018, 47 million of the medical consultations they provided and 31 million prescriptions were issued online. 5 The company Willis Towers Watson assessed cost effectiveness indicators in a study with the title "Current telemedicine technology can mean big savings, " published in 2014. 6 The study suggested that telehealth had the potential to save more than $6 billion a year for companies in the United States. It constitutes an important tool within healthcare and there is evidence that it has an economic impact on national healthcare systems. 7,8 Use of telemedicine as a component of integrated healthcare practices, such as preventive and chronic condition management programs, can be effective for clinical and administrative outcomes.
Its attributes include greater availability of attendance, access to electronic medical records, online requesting of diagnostic tests, electronic prescription, availability of scientific material to support clinical decisions and reduction of the average duration of consultations. Moreover, as healthcare services become organized increasingly through integrated logic models, telemedicine ceases to be a support service and starts to have a cross-cutting role in all care. 9 The Declaration of the 58 th General Assembly of the World However, soon thereafter, this resolution was revoked at the request of regional medical councils, after complaints by both professionals and entities through various arguments (lack of debate and in-depth assessment of the subject, risks to patients, potential loss of jobs and/or precariousness of medical activity).
Although telemedicine has been discussed and used in healthcare systems for many years, including the adoption of technological innovations such as artificial intelligence, in Brazil it is still not fully used by healthcare professionals. However, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has stimulated its use, particularly since the Ministry of Health published its Ordinance 467 on March 20, 2020, authorizing the use of teleconsultation. 12 This enabled the continuation of a direct relationship between doctors and their patients, including for making diagnoses and defining treatments, during the healthcare crisis.  16 On the other hand, a systematic review of outpatient telehealth implementation in the United States during the COVID-19 global pandemic identified three barriers impacting the implementation and use of telehealth resources: patient telehealth limitations, lack of telehealth guidelines for clinical care and issues relating to training, technology and finance. 17 In the existing literature on telehealth, there has been consistent emphasis on the importance of recognizing the complexity of implementing telehealth services for successful and sustainable use.
There are also multiple interdependent dimensions of telehealth to consider, including processes, user-experience and sustainability. Correspondingly, the design and implementation of telehealth services often involves engagement of stakeholders from a variety of disciplines, both within and outside the setting of the organization, including healthcare providers, managers, administrators, patients, information and communication technologists, economists and policymakers. 18 With the rise of the COVID-19 pandemic, the course of telemedicine underwent a major upswing. As shelter-in-place became the norm around the world, patients and clinicians had to adapt to a new, yet not novel, way to provide medical care. Use of telemedicine will continue to grow in the post-pandemic world, but its development will depend on several factors. Some of those factors are related to patients, some to the physician and their practices and some to reimbursement. 15 This article tries to fill the gap in the literature regarding the short-term reaction of physicians in the state of São Paulo, Brazil, to the use of telemedicine/teleconsultations after this procedure became officially approved in this country, due to the SARS-CoV-2 pandemic.

OBJECTIVE
To describe some aspects of use of teleconsultation among a sample of physicians in the state of Sao Paulo during the SARS-CoV-2 pandemic. States). These data were then tabulated for descriptive analysis, considering absolute and relative frequencies.

RESULTS
This survey, which was available via electronic means from an employment relationship with the organization in which they worked (46; 4.8%), as shown in Table 3. These findings highlight that many professionals started to remotely care for their former patients, on a temporary basis. With reorganization of care, after the emergency situation, this scenario will probably tend to change.
Regarding the experiences of patients who used the attendance provided through telemedicine, most of the physicians reported that the users accepted and liked the experience (788; 51.5%).
However, 678 (44.3%) said that their patients accept this form of attendance only because of the SARS-CoV-2 pandemic but did not really like it. Another 64 (5.9%) said that their patients did not agree to use this resource.
Telehealth does not consist merely of transposition of faceto-face care to a virtual environment. It is permeated by actions of education, care, diagnosis and procedures. 11 It requires training for proper and efficient use of the tools available. The present survey revealed that, out of the total number of respondents, 1,607 (88.33%) had not participated in any educational activities relating to telemedicine and that 27.97% (574) did not have any interest in participating in this in the future. Among the physicians who had participated in training activities, the majority had attended programs of duration less than four hours (238; 11.6%). In this context, the need for training professionals to provide care using the resources of telemedicine becomes relevant. Recently, a Brazilian guidebook for remote consultation was published and, certainly, other resources will be made available to Brazilian professionals. 3

DISCUSSION
Telemedicine has been widely used in several countries. Legal and regulatory issues still prevent it from advancing in Brazil. Its emergency use due to the SARS-CoV-2 pandemic has stimulated the entry of new service providers into the market and the use of information and communication technology (ICT) resources in a somewhat improvised way by professionals.
Telemedicine has the potential to increase the capacity for case resolution and facilitate coordination of care and therapeutic adherence. It can consequently reduce hospitalizations and unnecessary searches for emergency services. In terms of patient safety issues, its use during the pandemic can be considered to have constituted an appropriate use of resources, thereby reducing the misuse of face-to face consultations.
Although this use of telemedicine resources was an innovative experience for many of the physicians surveyed, the results from this study revealed that almost half of the respondents did not use telemedicine. In addition, more than a quarter of the participants who used it (28.4%) did not receive payment for the care they provided.
Telehealth needs to be part of an integrated care model, with action in a network. Telehealth should contribute to facilitating access to services, while maintaining coordination of care that is  Many physicians used telemedicine as support for their existing patients. It is known that there are more effective results when remote consultations are integrated into comprehensive healthcare. 2,8,9 However, in the present study, many physicians who undertook telemedicine as a source of care did not use dedicated platforms (38.4%); nor did they use electronic health records (38.6%) or electronic prescriptions (27.4%). These resources are important for care to be provided in a more professional manner, so as to ensure the conditions for increased patient and provider safety, information integration and patients' adherence to treatment.

Limitations
The unquestionable limitation of this analysis relates to the sample analyzed: out of the total number of questionnaires distributed, only just over 2,000 were answered, which represents about 4% of the possible sample size. Moreover, even in this sample, only about 50% of the respondents said that they had been using telemedicine. This shows that although there was unclear risk of bias among the respondents, existence of this risk has to be recognized. In addition, the survey was applied only to physicians working in the state of São Paulo and is therefore not representative of the universe of Brazilian professionals.

CONCLUSION
Currently, there is an international consensus that telemedicine is an important tool for medical practice that facilitates access to care, based on incorporation of new technologies and integration of the dimensions of prevention, diagnosis, treatment and monitoring. The SARS-CoV-2 pandemic has led to rapid adoption of telemedicine in various parts of the Brazilian healthcare system. However, as demonstrated in this study, important issues such as professional remuneration, use of electronic platforms and medical records, ensuring data protection and relationships between physicians and other stakeholders (healthcare insurance plans, hospitals and diagnostic centers) still need to be better defined, in order to achieve the desired scale and reach the outcomes defined.