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Implementing RUTE´s Usability - the Brazilian Telemedicine University Network

 Wilson Biancardi Coury 1, Luiz Ary Messina 1José Luiz Ribeiro Filho 1, Nelson Simões1, Grace Dal Sasso2, Sayonara Barbosa2, Lilian Prates Behring 3, Glaucia Aguiar4, José Carlos Lima de Campos4

1 Rede Nacional de Ensino e Pesquisa (RNP), Brazil; 2 Universidade Federal de Santa Catarina, Brazil; 3 Universidade Estadual do Rio de Janeiro, Brazil; 4 Universidade Federal do Rio de Janeiro, Brazil

AbstractThe Brazilian eHealth initiative enables videoconferencing, diagnosis and formative second opinion, continuous and permanent education and web conferencing, by linking university and teaching hospitals via RNP (Rede Nacional de Ensino e Pesquisa), Brazil’s national research and education R&E network. It operates two significant national projects: The Telemedicine University Network, RUTE (Rede Universitaria de TElemedicina www.rute.rnp.br) and the National eHealth Primary Care Program, Brazil Telehealth (www.telessaudebrasil.org.br); respectively from the Science and Technology Ministry MCT and Health Ministry MS. The municipal, state, national and international health institutions coordinate collaborative projects in research, innovation, development, management, education and assistance.

Keywords: telemedicine, eHealth, videoconference, webconference, teleimersion

Introduction

RNP leads the Telemedicine University Network RUTE, funded by the Brazilian Ministry of Science and Technology, through FINEP the Brazilian Innovation Agency, research and  projects financing.  RUTE seeks to build and update the communication infrastructure of the Brazilian public university and teaching hospitals with the goal of enabling all participating hospitals to use the RNP network to run telemedicine and telehealth applications, including video and web conferencing for information exchange, collaborative research, remote assistance, second opinion and continuous education. Private institutions may also participate on their own costs. 

RUTE´s main objectives are:

·         Connect the University and Teaching Hospitals to Brazil’s national research and education R&E network through a 1Gbps City Fast Ring for R&E Institutions

·         Formally create an eHealth Nucleus in each Hospital

·         Homologate a Videoconference Room

·         Create initial infra-structure for Teleconsult and Telediagnosis

·         Train Personnel for Video- and Webconference

·         Create and stimulate participation in SIGs – Special Interest Groups

       In its first phase, started January 2006, RUTE resources were available for 19 University Hospitals¹. Second phase, January 2007, included 38 institutions involving all University Hospitals from all Federal Universities in all federal states and 26 embrio institutions according to an agreement between RUTE/RNP and Telehealth Brazil. Third phase, started May 2009, selected 75 institutions, involving all public certified teaching Hospitals, federal health institutions and the federal indigenous health department.

       The Ministry of Health integrates the initiative through the Telehealth Brazil, implanting initially in 9 states the remote Primary Care Program in the University Hospitals attending 100 Municipalities in each state, yielding 900 operational at the moment.

Advanced Network Infrastructure

RUTE implements communication infrastructure in university and teaching hospitals in the largest 53 cities in Brazil, enabling the establishment of telemedicine and ehealth centers with investments on equipment, connectivity and ambience preparation. The goal of the project is allowing all participating hospitals to use the National Network for Education and Research in order to operate applications on telemedicine and telehealth, including video and webconference for exchanging information, talks, continuing education, formative second opinion and teleconsultation, creating a base for collaboration among hospitals and training them for remote collaboration.

The R&E Metropolitan Community Networks (Redecomep) implements communication infrastructure in the 27 Brazilian capital cities through its Points of Presence (PoPs - www.redecomep.rnp.br ). It expands now to 10 more cities. The goal of the project is to connect all main public universities and research centers in the country, with optical fiber managed by a local consortia made up of these institutions and RNP. However, the participation of state and municipal governments on R&E networks is opening up new possibilities including public schools and health care centers.

These metropolitan networks are being installed and full operation is expected by 2010 in the capital cities (Figura 1). Currently, sixteen capital cities operate the Redecomeps with 290 institutions.

Metropolitan networks are connected nationally by the National R&E Network backbone with current Gigabit connection capability in ten PoPs (10Gbps for Rio de Janeiro, São Paulo, Brasília and Belo Horizonte and 2,5 Gbps for Porto Alegre, Florianópolis, Curitiba, Fortaleza, Recife and Salvador) – http://www.rnp.br/backbone/index.php . All 10GB is coming.

RUTE Operational Methodology

       The following procedures are implemented for setting the structure of the Telemedicine University Network operational methodology:

·         Establishment of the organizational and technological infrastructure: national coordination, advisory committee  made up of telemedicine experts of the country’s best teaching and research institutions, interest groups on specific health areas and also executive, maintenance, communication and operational teams of the national and local telemedicine and telehealth network;

·         The Advisory Committee (CA-RUTE) recommends the procedures for the innovative use of the Telemedicine University Network;

·         Each member institution establishes the telemedicine and telehealth Nucleus/Center with a physical area and a dedicated team;

·         Member institutions establish SIGs to promote and develop collaboration activities on telemedicine and telehealth specific topics;

·         Organize workshops to encourage everyone’s understanding of the collaboration work for the national integration on teaching, research and the improvement of health care service for the population³.

A.     Implementing Network Phase I

Implementation Phase I is concluded. All 19 University Hospitals (HUs) and their formally created Telehealth Centers are fully connected and operational. The institutions received equipment and implementing services according to each Project and Workplan. All connected in the NREN communication infraestructure from RNP, participate regularly in video- and webconferecing sessions. The institutions involved in this phase are: UFPR, Unifesp, Pazzanese, Unicamp, Ufes, UFBA, Ufal, UFPE, UFPB, UFC, UFMA, Ufam, FioCruz, HC–FMUSP, HU-USP, ISCMPA, Uerj, UFMG, UFSC, almost all, hospitals from federal and state universities.

B.     Implementing Network Phase II

17 out of 38 members of phase II and their formally created Telehealth Centers are fully connected and operational. The others have already received all equipment and should be fully connected and operational in 2010. The institutions involved in this phase are all university hospitals from federal universities and 5 health faculties from federal universities without yet university hospitals, in demanding regions in the so-called Legal Amazonia in the states of Amapá, Roraima, Acre, Rondonia and Tocantins.

C.     Implementing Network Phase III

Phase III started May 2009 incorporated 75 new institutions, 60 Teaching Hospitals and 15 federal health institutions. 50 institutions have already submitted their projects, goals and list of equipment to constitute the Nuclei. These institutions will be signing the cooperation terms with RNP in 2010 for receiving equipment and connection.

D.     Implementing Usability

To guarantee high network efficiency, the advisory committee   focused on answering the following questions:

Which services are essential to run a Telemedicine University Network and create a virtual health community ?

1.    Enable communication infrastructure;

2.    Guarantee integration and service quality;

3.    Stimulate collaborative research, interinstitutional formal courses and health assistance;

4.    Involve main actors: government, university, enterprise;

5.    Indicators to evaluate services;

6.    Stimulate and coordinate national and international Special Interest Groups.

Which other factors guarantee demand and sustainability ?

1.    Health professionals are highly creative building applications and developing new eHealth ICTs (information and comunication technologies);

2.    The majority of health professionals will be affected by eHealth ICTs in research, education, diagnosis, management and assistance;

3.    Introduction of health informatics, telemedicine, telehealth, bio- and nanotechnology in health universities will strengthen the national health system.

4.    SIGs are created and coordinated by members RUTE; health professionals build the annual vídeo- or webconferences sharing specific themes. The sessions per month, week, debate cicle, defined by the group, may be focused on education, research and assistance, by formative second opinion.

There are 37 SIGs today with more than 250 Video- and webconference sessions in 2009 and almost double as much in 2010: Cardiology, Pediatric Cardiology, Surgery and Traumatology, AIDS, Nursing in Intensive Care and High Complexity, ENT-Ear Nose and Throat, Management Teaching and University Hospitals, Rural Internship, Neuroradiology, Dentistry - Oral Diagnosis, ophthalmology, Onco-Gynecology, Standards for Telemedicine and Health Informatics, Telehealth Research, Development and Innovation, Quality and Safety in Hospitals Sentinel Network, Abdominal Radiology, Radiology and Diagnostic Imaging in Pediatrics, Radiology and Diagnostic Imaging in Chest, Health Children and Adolescents, Nursing Services, Technical Operations in Telemedicine Centers,  Telecoloproctologia, teledermatology, Telenursing, telepsychiatry, Tele Network Human Milk Bank, Clinical Toxicology, Urology, Pediatric Urology, Endometriosis.

The number of institutions participating in the periodic sessions have surpassed 70 and 400 persons (Fig.2), including Rute members and other institutions. Implementing phase III, the number of participating institutions will enlarge as also the diversity of specific themes and operations, as already suggested by the newcomers according to their projects.

The Nursing SIGs

As a reflex of the collaborative activities already existent among nursing professionals, 3 SIGs have early started operating under RUTE Network.

SIG – TeleNursing SC (Santa Catarina state) was the first nursing group created in 2007, aiming the integration of informatics and ehealth in intensive care and emergency, besides research and education. Since its start 29 clinic teleimersions were set using the methodology of case based education exercising evidence based nursing in intensive care and emergency. Besides these activities the group meets and focuses on research related to the state of Santa Catarina Nucleus on Patient Protection (Polo de segurança do paciente no Estado de Santa Catarina), which is integrated to the Brazilian Network on Patient Protection (Rede Brasileira de Segurança do Paciente (REBRAESNSP)) and the Clinic Research Group, Technology and eHealth (Grupo de Pesquisa Clínica, Tecnologias e Informática em Saúde e Enfermagem (GIATE-UFSC)). 13 hospitals in Brazil participate with a total of 100 participants in each collaborative session. An international videoconference will take place by the end of this year in order to disseminate and promote emergent technologies applied to nursing care, research and education, with practical developed examples. Still in 2010 the participants of the group will meet and establish learning quality indicators, based on these technologies and methodologies, as well as plan the next activities in 2011.

SIG Intensive Nursing was created in January 2009, with the understanding that high complex health activity is a set of actions that occur in situations involving imminent danger to life or critical care / emergency. These activities take place at all levels of health care, as in Service Mobile Emergency Care - SAMU, the emergency care units - UPA, primary care health units, hospitals and home care environments. The group aims to develop a permanent process of education in intensive care nursing in Brazil; to promote and develop collaborative assistance and research in intensive care nursing; to integrate high complexity care with primary care in order to improve the quality of care and to reduce unnecessary health costs. It started with 5 members and nowadays has been consolidated as a representative portion of Brazilian nursing, with the amount of 83 institutions including hospitals, emergency service units (PSUs), regional and national class societies. The results surpass the initial expectations of RUTE network, which was to cover university hospitals, and demonstrates the necessity of integration with other levels of health care. Since the intensive nursing SIG was created, 17 videoconferences have been performed on several topics, selected through vote by regional leaders. An amount of 1860 certificates have been issued to participants who are mostly nurses, but there are other health groups such as physicians, dentists, pharmaceutists, nutritionists and physical therapists, demonstrating the importance of the multidisciplinary discussion.

SIG TeleNursing Mental Health aims to integrate professionals, students, researchers and professors in order to promote discussions in psychiatric nursing and mental health focusing on various aspects of care, teaching, learning and research. These collaborative sessions induce and formulate proposals among the participants, enhancing the agenda, for the construction of nursing assistance protocols, publications and methodologies. It should be emphasized the unique approach in this area and the wide amplitude it is enabling. Launched during the Nursing Brazilian Week (SEMANA BRASILEIRA DE ENFERMAGEM) in Rio de Janeiro, in partnership between the Federal Universities of Rio de Janeiro UFRJ and Maranhão UFMA, and the State University of Rio de janeiro UERJ, it has today partners in the south east, north and north east of Brazil.

Network results

       RUTE member projects integrate at the moment 158 health institutions. It connects today 38 Nuclei and 31 embrio-Nuclei fully operational.

RUTE performs daily routine VC videoconference or Webconference sessions, each specialty at least once a month, on pediatrics radiology, oncology, urology, children and adolescent health, dermatology, cardiology, oftalmology, etc. There are 37 SIGs operational in 2010. A total of ca. 250 sessions were held in SIGs in 2009 and double as much already in 2010 (Fig.2).

There has been a 137% increase in the participation of institutions in the groups in 2009, from 89 to 211institutions, including invited institutions. In some groups up to 400 people participated from remote areas in specific sessions on intensive nursing.

Telehealth Brazil shows already results implemented in 9 states, 9 RUTE Nuclei, assisting 2700 teams of the Health Family Program PSF in 900 municipalities, covering 11.000.000 inhabitants. 4 new states are already starting their activities.

In addition, as it happens with the added value of the program Tele Minas Saúde (Minas Telehealth Fig.1) financed by the State Government Health Department and coordinated by Prof.Dr.Beatriz Alkmin, ECG formative second opinion is guaranteed for each of the 600 municipalities, on duty service 12 hours, 7 days per week shared with the following National University Hospitals: UFMG Universidade Federal de Minas Gerais, UFU Universidade Federal de Uberlândia, UFTM Universidade Federal do Triângulo Mineiro, UFJF Universidade Federal  de Juiz de Fora and Unimontes, yelding more than 900 consults and formative second opinion per day.

An entrepreneurial integrated ministerial approach is also being articulated in order to establish a common strategy at national level on health focused relevance, guidance and sustainability aspects, taking into account entrepreneurial plans and partnership with the RUTE members, enhancing market oriented R&D Nuclei activities. One of the pre-requisites of the FINEP Call 1-2010 on Telemedicine for universities and research institutes stated enterprise participation.

International Collaboration

       The encouragement for the continuous development in this area comes from the following mechanisms:

·         Cooperation signed between Internet2 and RNP in Health Sciences;

·         Program for Innovative Continuing Medical Education in Dermatology, with the American Academy of Dermatology and the University of Miami;

·         Laboratory of Excellence and Innovation in Telehealth – Latin America and Europe, in Belo Horizonte;

·         Establishment of a SICOT (International Society of Orthopaedic Surgery and Traumatology) Tele-Education Center on orthopedics and trauma in São Paulo and Rio;

·         Regional Protocols for Public Policies on Telehealth in Latin America, an IADB project, started October 2009. The Health Ministries from the following countries signed the letter of compromise: Brazil, Colombia, Ecuador, El Salvador, Mexico, Uruguay, RNP and RedClara³.

RUTE is also been used as an innovation example in scientific collaboration, enabling the development of nuclei in the university hospitals and researchers integration  in all regions in Brazil. It is being considered relevant and innovative by the University Corporation for Advanced Internet Development (UCAID – Internet2) and Terena (Trans-European Research and Education Networking Association), as stated by the Internet2 Health Sciences coordinator Michael McGill in the 1st Terena Day Networking Conference 2009 in Malaga, Spain: “Real-life impacts of networking Technologies - Telehealth structures are less advanced in the USA, according to Michael McGill, who is responsible for health sciences for Internet2” (http://tnc2009.terena.org/media/news.php#n2439). 

IADB, the Interamerican Development Bank appoved in 2008 the project Telehealth Public Policies in Latin American. The contract has been signed in October 30th and launched in December 9th 2009 in Belo Horizonte, Brazil, during the II Workshop of the Laboratory of Excelence and Innovation in Telehealth Latin America, and the IV Brazilian Congress on Telemedicine and Telehealth, with more than 700 participants, 30 of them representing 20 countries. The main components of the project are:

1.                              Regional Standards for transmission and infra-estructure

2.                              Strategy for the promotion, prevention and assistance through telehealth

3.                              Regional guide for telehealth managing

4.                              Strategy for a  Latin America Telehealth University Network

5.                              Telehealth training and certification

The project period amounts 36 months. Other countries will be able to participate and contribute in the 3 project workshops, also because other resources/funds for their participation is being articulated with CEPAL. A following proposal is under way to enlarge LA participation in SIGs. The Nursing Groups are included in this proposal for LA. 

Conclusion

Previous research projects at the Brazilian universities showing remote assistance, education and collaborative research, also stimulated by the @lis results⁴, including RedClara for interconnecting Latin America NRENs, encouraged government actions and public investments on communication infrastructure, telemedicine and telehealth.

From the new 75 RUTE members 50 have already approved their projects and 22 are already signing the cooperation agreement to implement the Telemedicine Nuclei.

Telehealth Brazil is also enabling the expansion to all 27 federal states through the Ordinance Nº 402⁵.

The main reasons for the continuity and success of the network in Brazil are: federal initiative and coordination, state initiatives, integration and synchronization between the two main complementary projects and members: RUTE (Ministry of Science and Technology) and Telehealth Brazil (Ministry of Health)6.

Ackowledgments

          To all RUTE members, the RUTE Committee, the National Telehealth Primary Care Program, the Brazilian National Education and Research Network RNP, Brazilian University and Teaching Hospitals Association Abrahue, Ministry of Education, Ministry of Health, Ministry of Science and Technology, and the Brazilian National Studies and Projects Financing Agency FINEP.

   

Figura 1 RNP national backbone; Brasília Redecomep R&E Network; 600 municipalities covered

 by the Minas Telehealth in the state of Minas Gerais

   

Figura 2 - Shows: The increasing number of SIGs in operation, RUTE member institutions

participating and a videoconference with 37 Nuclei in all 27 Brazilian states on Dengue prevention.

  

Figura 3 - A NOTES transvaginal colecistectomy surgery performed and transmited at ISCMPA by Prof.Dr.Luiz Alberto de Carli on Sept 30th 2008.

References

1. RUTE – Rede Universitária de Telemedicina, Convênio Encomenda-FNDCT Ação Transversal ret. 2738/05, (UFPR, Unifesp, Pazzanese, Unicamp, UFES, UFBA, Ufal, UFPE, UFPB, UFC, UFMA, Ufam, FioCruz, HC-FMUSP, HU-USP, ISCMPA, Uerj, UFMG, UFSC), January 2006.

2. Ministério da Ciência e Tecnologia, Ministério da Educação, Ministério da Saúde CT, MEC e MS. Os Hospitais Universitários e a Integração Educação, Saúde e Ciência e Tecnologia. Workshops de Telemedicina e Telessaude promovidos pelo Conselho Federal de Medicina nas regiões do Brasil: Norte, Março 2007, Manaus; Nordeste, Maio 2007, Recife; Central, Julho 2007, Brasília, e os Congressos da SBIS, Abrahue e do CBTMS em 2007/-7/-8/-9.

3.  ATN/OC-11431-RG, Protocolos Regionais de Política Pública para Telessaúde, 30/10/09, Fundep/UFMG, Banco Interamericano de Desenvolvimento BID.

4. IV European Union – Latin America and The Caribbean Ministerial Forum on the Information Society, @lis, An Alliance for Social Cohesion through Digital Inclusion, Rio de Janeiro, 22-23 November 2004, Rio de Janeiro Declaration, VI Forum in Lisbon, 28-29 April 2006, Lisbon Declaration.

5. Portaria nº 402, de 24 de fevereiro de 2010, Diário Oficial da União Seção 1, N.37, 25/02/2010.

6. RUTE Forum, HU-UFRJ, RJ, 10-11/08/2009.