Perception of Health Care Providers and Users on Teleconsultation in Times of COVID-19 in Brazil: An Exploratory Interview Study

Introduction

Telemedicine and telehealth involve the provision of health services for diagnosis, treatment, prevention, research, and education when the provider and the user are in different places. This service has been consolidated with the development of Information and Communications Technologies (ICT) since the end of the 20th century.^1,2 There is a conceptual inconsistency regarding the use of the two expressions, especially concerning the scope of services, restricted to physicians or extended to other health providers.³ In this study, both terms are used interchangeably.

Among their applications, teleconsultation involves the exchange of information between a health provider and the patient, and the appointment can occur without face-to-face encounters.⁴

The COVID-19 pandemic has had a strong impact on various socioeconomic activities, especially those that require face-to-face meetings, as in the case of health services. Thus, teleconsultation has helped to reduce the level of contact between people and prevent the spread of the virus, in addition to providing resources for the care of uninfected users.⁵

The COVID-19 pandemic led to an appreciation of the remote dimension and health care and, despite some opposing aspects and restrictions on its use in Brazil, temporary mandates, which changed the legislation and regulations in force, were issued to expand the use of teleconsultation, resulting in a growing offer of this service in the public and private sectors.

This work was aimed at examining the perception of health care providers and users regarding virtual care in Brazil.

CURRENT TELECONSULTATION

In the context of the COVID-19 pandemic, telehealth services in Brazil have played a key role in the fight against COVID-19, whose landmark was the Federal Law No. 13,989, March 2020, for the purposes of assistance, research, disease and injury prevention, and health promotion.⁶

Also in March 2020, through a letter sent to the Ministry of Health, the Brazilian Federal Council of Medicine (CFM) recognized the possibility and ethics of using telemedicine for remote guidance, monitoring, and consultation.⁷ Then, through ordinance No. 467, the Ministry of Health expanded the provision of services beyond the limits established by the CFM to include preclinical care, care support, consultation, monitoring, and diagnosis.⁸

To expand and qualify the workforce to face COVID-19, the Ministry of Health published ordinance No. 639 requiring mandatory registration for a limited period of time, while public health emergency is declared, for 14 categories of health care providers from the federal councils of Biology (CFBIO), Biomedicine (CFBM), Physical Education (CONFEF), Nursing (COFEN), Pharmacy (CFF), Physiotherapy and Occupational Therapy (COFFITO), Speech Therapy (CFFA), Medicine (CFM), Veterinary Medicine (CFMV), Nutrition (CFN), Dentistry (CFO), Psychology (CFP), Social Service (CFESS) and Technicians in Radiology (CONTER).⁹

Despite being restricted to the medical profession, ordinance No. 467 influenced other professional councils to take a position on the use of teleconsultation in their area of expertise (Table 1).

The positions of the federal councils vary greatly regarding the use of teleconsultation. CFBIO, CFBM, CFF, and CONTER have not taken a position; CONFEF does not have any regulations, despite the number of service offers on various platforms and social media; CFMV, CFO, and CFESS vetoed its use and remained with this restriction even during the COVID-19 pandemic; COFEN, COFFITO, and CFP have temporarily authorized its use; CFN and CFFA authorized its use on a definitive basis; and CFM, despite not having authorized teleconsultation, has been using it in light of the provisions of ordinance 467 of the Ministry of Health.

Thus, the pandemic expanded the use of teleconsultation, which has been used by the Public Health System (Sistema Único de Saúde, SUS) and by private health service providers. Regarding SUS, it is worth mentioning the TeleSUS, Tele-UTI, and Regula Mais Brasil projects, initiatives undertaken by various state and municipal health departments and public health institutions, among many other examples. Regarding private institutions, it is worth mentioning the offer of this service by reference hospitals, main insurance companies, private health providers, and several other initiatives.^10,11

Two public initiatives in 2020 should also be highlighted: the creation of Frente Parlamentar Mista de Telessaúde (Joint Parliamentary Telehealth Front in the National Congress), aimed at drafting a specific law to establish telehealth as a permanent application in Brazil; and the launch of the Digital Health Strategy for Brazil 2020–2028 by the Ministry of Health to develop digital health in the country, which includes teleconsultation.^12,13

Methods

In October 2021, searches were carried out for 2020 and 2021 in the Scielo and PubMed databases with the descriptors “teleconsulta” and “teleconsultation,” identifying 27 and 1,686 articles, respectively, from different countries. Among these, 37 (2%) simultaneously address the perception of users and professionals, of which only one was developed in Brazil. This aspect signals the relevance of this work, especially as the sample is national with 1,089 participants.

Field data were obtained between June 17, 2020 and August 3, 2020, a period that corresponded to high rates of COVID-19 contamination and deaths in Brazil, through two semistructured questionnaires, one for each group of respondents. As the research instruments most used for this purpose in the literature do not consider these aspects together, we chose to develop our own research instrument.¹⁴

It is a cross-sectional study using quantitative and qualitative methods to obtain and analyze the data using the survey as a methodological procedure, which is recommended when you want to investigate a problem whose answer depends on direct information provided by the participants.¹⁵

Providers from the 14 categories defined by ordinance No. 639 of the Ministry of Health were considered health care providers and the users were the general population.⁹

Nonprobability sampling was obtained using the snowball sampling, in which the initial respondents were encouraged to invite other participants until the desired sample was obtained. To increase the heterogeneity of the sample, the initial contacts included representatives of the federal and state councils of the 14 professional categories, municipal health and education councils, Research National Council (CNPq) research groups, and students from the last 10 years of the Sergio Arouca National School of Public Health.

The minimum sample size was determined for the 95% confidence interval (CI), a type 1 sampling error of 0.05, and a low effect size of 0.2, to maintain the same confidence level for a low correlation between the data, reaching a minimum of 262 participants per group of respondents, with an effective sample of 480 and 609, respectively, for providers and users.¹⁶

The questionnaires were developed in four consecutive stages: preparation of the preliminary version, validation, test by three users and two health care providers, and adjustments, and they were organized in three parts. The first part provided demographic data of the respondents. The second was aimed at obtaining their perceptions on teleconsultation when compared with face-to-face appointments, through six categories of analysis: quality, remuneration, duties, and responsibilities, which are pointed out by the literature as restrictive factors to its dissemination; experience and positioning regarding use, which aimed at identifying perceptions related to the respondents familiarity with teleconsultation, and technology, to verify those that were used for remote appointments.¹⁷ To obtain a broader perspective, the third part consisted of two open questions, limited to a single word, and provided subsidies for a qualitative analysis regarding the benefits and harms of telemedicine.

Google Forms were used to apply the questionnaires, because of the platform’s resources to organize the survey, control the answers, and process the data.

The questionnaires were made available in the cloud and could be accessed through a link sent by email or WhatsApp.

The data were stratified from the paired correlations between the categories of quality, remuneration, position, and experience, and between these categories and the variable “service network,” for which chi-square tests were used with the statistical software R, p-value of 0.05 and CI from 2.5% to 97.5%. This stratification was performed for all pairs, in which the correlation was >50%, excluding the categories “technologies” and “duties and responsibilities,” as they were not significant for the study.

For the qualitative analysis, the “word cloud” technique proved to be sufficient, using the Wordle application, without the need for additional techniques.

This research was approved by the Ethics Committee opinion No. 4,042,721—National School of Public Health (ENSP/FIOCFRUZ), CAAE 31353520.8.0000.5240 on 05/22/2020.

Results

A total of 1,089 respondents participated in the survey, of which 480 were health care providers and 609 were users. All regions were represented with a majority participation from the Southeast (66% of providers and 77% of users) and greater concentration in the capitals (59% of providers and 78% of users).

Among the health care providers, the 14 categories were represented, with a greater participation of those affiliated to COFEN (31%), CFM (23%), and CFP (9%), with a large participation of doctors and nurses, the majority of providers in the front line in the fight against COVID-19.

Among the providers, most of them worked in the public health system, and 59% work exclusively in this system. However, 11% work in both the public and private systems which makes a total of 70% in the public system. Regarding the patients, most of them, 62%, use the private network, only 13% use the public network exclusively, and 24% use both.

Next, the percentage distribution of the answers related to the perception of professionals and users regarding the six categories are analyzed (Table 2).

It is worth mentioning that 46% of health care providers have already had experience in providing teleconsultation services and 37% of the users have used these services.

According to 61% of health care providers and 50% of users, the face-to-face appointments have a superior quality when compared to teleconsultation, but 31% of both groups consider both services to be of the same quality.

Regarding remuneration, 46% of health care providers and 60% of users believe that the face-to-face service should be higher than the remote one, while 37% of providers and 23% of users think that should be the same.

The data show that 87% of health care providers and 86% of users understand that duties and responsibilities should be the same, regardless of whether the service is remote or face-to-face.

Regarding the use, among the 97% who would somehow use teleconsultation, 37% of health care providers and 39% of users would use it whenever possible.

As for the technologies used, the result showed the predominance of WhatsApp, telephone, and webinar/video calls.

Next, the data stratification of the categories of quality, remuneration, position, and experience and of these with the variable “service networks” are analyzed (Table 3).

Among providers, the perception of quality is influenced by experience, remuneration by the “service network,” experience and quality, and position regarding quality. Among users, there are slight variations. The perception of quality is not influenced by experience, remuneration is influenced only by experience and quality, and positioning is influenced by quality.

To complement the respondents’ perception of the use of telemedicine in general, they were asked to identify in a single word the greatest benefit and greatest harm. As the set of responses from the two groups of participants was quite similar, Figure 1 presents the integrated responses, with the 30 most cited words.

In terms of benefits, access, practicality, agility, accessibility, easiness, comfort, and so on stand out. Regarding harms, concerns such as contact, quality, distance, errors, quality, and impersonality, among others, stand out.

Discussion

Most respondents were from the Southeast and respective capitals, as well as health providers working at the public health system. The technique adopted for dissemination, associated with regional differences in terms of socioeconomic development, access to technologies, network of knowledge, and interactions of the researchers involved, among other aspects, helps to explain this result, and indicates a limitation of this study.

Both groups have great experience in the use of teleconsultation, whose use was expanded during the COVID-19 pandemic. Reinforcing this aspect, a survey conducted by the São Paulo Medicine Association (Associação Paulista de Medicina, APM) in May 2020, with 2,808 health care providers from all over the country, pointed out that 48% of the respondents provided remote care, of which 24% were teleconsultation. In April, when the APM conducted the first survey on the topic, this rate was 19.7%.¹⁸ It is noteworthy that having previous experience can influence the perception of respondents in relationship to teleconsultation, as also pointed out by other studies.^19,20

The research shows that the quality of face-to-face service is superior to the remote service between both groups. However, attention is drawn to the fact that 31% consider the quality between the two types to be the same. These data are convergent with studies from China, France, Israel, and so on and, together with the experience shown above, indicate a relative acceptance of the use of teleconsultation.^21–25

Similarly, most respondents understand that the remuneration between services should be differentiated, with higher values for face-to-face services. However, three factors seem to influence the opinion of health care providers in relationship to remuneration: “service network,” experience, and quality.

As for the influence of the “service network,” among providers working in both systems (public and private), 62% think that the remuneration should be the same and 29% consider that face-to-face appointments should have higher remuneration than the remote ones. When considering the total of 480 respondents, 37% think that the remuneration should be the same, and 46% think it should be higher.

Regarding the influence of experience, among professionals who have already used teleconsultation, 48% consider that the remuneration should be the same and 36% consider that the face-to-face consultation is higher than the remote one. When considering the total of 480 respondents, 37% think that the remuneration should be the same and 46% think that it should be higher. Among the providers who did not use teleconsultation, only 25% think that the remuneration should be the same and 55% consider that the face-to-face consultation should have higher remuneration than the remote one. In other words, having previous experience in teleconsultation influences the providers’ view of their own remuneration.

Regarding the influence of quality, among providers who understand that face-to-face appointments are superior to remote ones, 57% think that face-to-face remuneration should be higher, a larger percentage than that of the total of the 480 respondents, of whom 46% believe that it should be higher. Similarly, the portion that considers that quality and remuneration should be the same is higher than that of the total number of respondents (60% × 37%). That is, the respondents’ opinion regarding remuneration is influenced by their perception of quality.

The issue of remuneration remains one of the controversies in relationship to teleconsultation, and the need to improve remuneration and reimbursement models has been pointed out in other countries as a prerequisite for greater adoption.^26–28

In Brazil, these aspects are not sufficiently addressed in the current regulation, especially in the provision of private services, and the National Supplementary Health Agency (ANS) is studying alternatives to paying for these services.²⁹

It is noteworthy that this discussion is also inherent to the SUS, given the importance of contractualization and remuneration for private services. Studies point to SUS difficulties in hiring quality services in a scenario of fiscal austerity, for which digital solutions cannot be neglected.³⁰ In other words, this issue is important, remains open, and needs further discussion.

As for the duties and responsibilities category, there is a convergence of position between the two groups. About 86% understand that providers have the same duties and responsibilities, regardless of whether the service is remote or face-to-face.

In relationship to the position regarding use, about 97% would use teleconsultation, although most would prefer face-to-face consultation. Surprisingly, the oldest (>60 years) had a similar position to the youngest, an indication that they are capable of adopting new technologies in health care, as pointed out in other studies.^23,31,32 This high satisfaction is consistent with international studies and suggests a growth in this application in the post-COVID-19 pandemic.^24,25,33,34

The analysis of the quality-position relationship regarding use showed that about 67% of the two groups that consider the quality of teleconsultation equal to that of face-to-face consultation would use it whenever possible; 81% of the providers and 62% of the users who would give priority to face-to-face assistance believe that its quality is superior to remote assistance. Therefore, the use of teleconsultation is influenced by the perception that respondents have in relationship to quality, as well as in terms of perceived benefits.³⁵

Regarding technologies, both groups of respondents tend to use WhatsApp, telephone, and webinar/videoconference for remote assistance, converging findings with other studies.^36,37 These results corroborate the concern of experts regarding the problems that may arise from the lack of patient data security with the use of these technologies.³⁸

It is worth mentioning the Brazilian General Data Protection Act (Lei Geral de Proteção de Dados, LGPD), effective from September 2020. The law provides for the collection and processing of personal data, regulating data protection and the privacy of citizens, and accountabilities.³⁹ That is, the concern of experts in relationship to safety is pertinent, with direct consequences in the relationship between health care providers and users with teleconsultation.

Among the benefits of telemedicine, both groups have the same understanding, highlighting access, but with relative differences in issues such as practicality, agility, comfort, and so on. These aspects point to the definition of telemedicine itself, which is the remote care of patients through ICT, breaking geographical barriers and expanding access to experts, and are in line with other studies developed in Brazil, U.S., England, and France.^19,25,32,40 Regarding harm, concerns such as distance, contact, quality, impersonality, precariousness, and dehumanization stand out, corroborating the disadvantages pointed out by scholars regarding the technological intermediation promoted in the provider–patient relationship.^19,41,42

FINAL CONSIDERATIONS

This research indicates that, although face-to-face care is favored, there is an important movement toward acceptance of teleconsultation, represented by experience, quality, and position regarding the use and benefits associated with telemedicine. This acceptance, certainly related to mobility restrictions imposed by the COVID-19 pandemic and to the strong publicity around telemedicine, showed, however, relative differences in perception regarding the six categories analyzed. For example, the majority of the respondents think that remote care shows a lower quality compared to face-to-face appointments, although this perception does not greatly affect the position regarding use, given that only 1% of the respondents would not use teleconsultation under any circumstances.

However, contact, distance, and errors are the main harms that stand out, in addition to other aspects such as dehumanization, precariousness, falsehood, and so on, criticisms commonly highlighted in the literature are in relationship to teleconsultation.

Although there is evidence of benefits and limitations, bringing to light contributions from the perception of health care providers and users can help to promote debates to establish teleconsultation on a permanent basis. Brazil and its public health system can benefit from this application of telehealth, as long as it is part of a broader and more humanized vision of care, which focuses on strengthening the SUS and which can effectively contribute to universal access in the territorial and socioeconomic conditions prevailing in Brazil.

Disclosure Statement

No competing financial interests exist.

Funding Information

This article had the financial support of the Fiocruz/Fiotec project “Challenges for the Unified Health System in the national and global context of social, economic, and technological transformations—CEIS 4.0” and the CNPq project “Science, Technology and Innovation in health for the SUS sustainability”.

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