The regulation of telemedicine, which currently operates on a provisional basis, has provoked a new clash within the medical profession, once again opposing two of the main entities in the category in the country, the CFM (Federal Council of Medicine) and the AMB (Brazilian Medical Association).
Throughout the Covid-19 pandemic, both have disagreed regarding early treatment with ineffective medications for Covid. The AMB has positioned itself against its use, and the CFM has left it up to doctors.
Now, the differences concern a central issue discussed both in the drafting of a new CFM resolution on telemedicine and in bills being processed in the Chamber of Deputies on the subject: the requirement that the first consultation be in person.
In virtual debates on the subject, the vice-president of CFM, Donizette Giamberardino Filho, has argued that the first telemedicine consultation should be in person. In a note sent to Folha, however, the entity said that it is still analyzing the matter. AMB, on the other hand, understands that this decision should be made by the doctor and the patient.
Teleconsultation services are offered by Hospital Sabará, in São Paulo, in several situations – Danilo Verpa/Folhapress
There are also discussions about the so-called territoriality. Could doctors practice telemedicine throughout the country or only in the states where they are professionally registered? Today, in addition to the certificate in the state where they predominantly work, doctors can have others in places where they also work.
The point is that now, with telemedicine, doctors can, in theory, treat patients anywhere in the country. AMB advocates that professionals should have the autonomy to do so.
Giamberadino Filho, from the CFM, has stated that if the first consultation is in person, the follow-up afterwards could be virtual, anywhere. In a note, the CFM says that it is still studying the matter.
“These [telemedicine] tools exist to benefit the patient. We still have limitations. There are situations in which I, as a doctor, will not be able to resolve everything [virtually]. I will need the patient in person,” explains gynecologist César Fernandes, president of AMB.
According to him, it is the doctor who, during the first virtual consultation, must decide whether or not an in-person consultation will be necessary. “It is the doctor's decision, the doctor's autonomy. If he ventures to make a therapeutic proposal without having all the necessary elements, he will be held responsible for it. It does not mitigate the doctor's responsibility if he sees in person or via teleconsultation.”
Research carried out by AMB with a representative sample of 980 doctors shows that 66% believe that the professional should have autonomy to decide whether or not to have a virtual consultation and 62% say that it should not be restricted to the state where the doctor has professional registration.
For Fernandes, the fact that part of the category defends that telemedicine should only be practiced in the state of registration may be due to the fact that there are doctors in places that do not have the technological resources to compete on equal terms with others from more advanced centers.
“Perhaps they think they will suffer losses. But it is the patient’s right to want to go wherever they want and with whomever they want. Otherwise, in a short while, doctors will have to have 27 CRMs to be able to provide telemedicine services in the country?” he asks.
Pediatrician Clóvis Constantino, professor of medical ethics and bioethics at Unisa (Santo Amaro University), points out that one issue that needs to be made very clear is that, for some medical specialties, telemedicine works very well, but for others, it does not.
He suggested to the CFM that the 54 specialties approve the way in which telemedicine could be used (or not) in their respective areas. “It is a way to use telemedicine safely. In psychiatry, for example, there is more safety [in a virtual first consultation]. But, in others, the physical examination, touching the patient, is very important.”
This Thursday (8), at 2 pm, there will be a public hearing in the Chamber of Deputies to discuss projects on the authorization of telemedicine and the security in the use of data during practice.
Under provisional legislation approved at the start of the pandemic and valid until the end of the health crisis, telemedicine is already being widely used both on structured platforms, which comply with confidentiality and data protection rules, and through informal means, such as messaging apps.
According to data from Saúde Digital Brasil, an association that represents the country's main telemedicine operators, between 2020 and 2021, more than 7.5 million virtual consultations were carried out by more than 52.2 thousand doctors. The vast majority (87%) of these were so-called first consultations.
For Eduardo Cordioli, president of Saúde Digital Brasil, more important than the volume of remote services is the high resolution rate: 91% in individual emergency care consultations.
“These are patients who had their problem resolved and did not need to go to the emergency room. And 1% of these appointments were essential to saving lives,” he says.
In Cordioli's opinion, limiting the use of medicine, whether by determining when a consultation should or should not take place remotely or by preventing doctors from treating patients from other states, leaves healthcare more vulnerable and nullifies attempts to bring care to regions that have previously been poorly served.
In the AMB survey, 561% of doctors said they are already providing remote care and 591% intend to continue after the pandemic. Another survey by FenaSaúde (National Federation of Supplementary Health) also shows widespread use of telemedicine by medical and dental care companies.
In a recent virtual debate promoted by Anahp (National Association of Private Hospitals) on the new role of doctors with telemedicine, one of the points addressed was the General Data Protection Law, which must be strictly followed by professionals who carry out virtual consultations.
“The pandemic has accelerated digital health processes and the plane has already taken off. It is very important to establish rules and ethical principles so that this implementation is within what we imagine to be appropriate,” said Giovanni Cerri, president of the board of the Radiology Institute of the Hospital das Clínicas in São Paulo.
“It is important to understand that consultations via WhatsApp are not telemedicine,” said Giamberardino, from the CFM. He stated that the council is studying ways to provide doctors with secure digital prescriptions and signatures, which are already included in the monthly fee.
Another issue is the training of doctors. According to Chao Lung Wen, associate professor and head of the telemedicine discipline at USP, only 12 of the 340 universities offering medical courses in Brazil have classes focused on telemedicine.
One concern raised by participants is that telemedicine should not be used by public and private health managers as a way to reduce costs and, for example, stop
invest in necessary local structures.
“It is irresponsible to think that telemedicine can replace everything. If a pregnant woman is experiencing bleeding, for example, an intervention may be necessary, so it is necessary to have physical structure,” he said.
For remote locations, he advocates a combination of mobile units and telemedicine. In such remote areas, where there is no doctor, Giamberardino says the first consultation could be virtual. “But it should be the exception, not the rule.”
In a note sent to Folha, the CFM said that issues such as the requirement for an initial in-person consultation (or not) or the definition of territoriality “are being evaluated, with rigor and criteria, based on considerations made by all sectors involved.”
“This effort has been carried out exhaustively so that Brazil can obtain a standard that allows the practice of telemedicine based on ethical, technical and legal principles,” he says.
Regarding the standard that is still under discussion within the CFM, he highlights that he has sought to listen to regional medical councils, specialty medical societies and renowned specialists to create a standard that meets the interests of patients and professionals.
Suggestions submitted through public consultation are also being analyzed, according to the CFM.
“It is important to remember that telemedicine is not intended to replace the presence of a doctor, but rather to improve the quality of the service provided, as well as access to it. Among the principles addressed in the review is the autonomy of the doctor and the patient. Valuing this relationship is essential for establishing interpersonal trust,” says the council.
The CFM also reiterates that it already has as a fundamental parameter, to be contemplated in the new resolution that will regulate the topic, that consultation and prescription platforms must offer elements of protection for the data received/transmitted.
It also understands that every medical act must be recorded in the patient's specific medical record, to provide greater security in the care provided.
Source: https://www1.folha.uol.com.br/equilibrioesaude/2021/07/uso-de-telemedicina-cresce-na-pandemia-mas-regulacao-enfrenta-embates-medicos.shtml?fbclid=IwAR1wZaDFssgx_5YZubzAVUyZz6yoRFrBaBgwSRpvJkH6xDF4JxIYb-GKTNo
