"The Use of Videotex Networks for Health System Support"

The Use of Videotex Networks for Health System Support: The Example of São Paulo, Brazil (*)

Ilana Fogelman & Eduardo O.C. Chaves

Contents

I. Introduction

II. Background

III. The necessity of Improving Epidemiologic Surveillance

IV. Objectives of the Present Project

V. Proposed Technology

VI. Pilot Project for the Evaluation of Technology

VII. Applications Supported by the Experimental Network

VIII. Discussion

1. Contributions of Videotex to the surveillance system

2. Considerations on acceptability and utilization

3. Considerations on Videotex's performance

4. General considerations

IX. Expansion

X. Conclusion

I. Introduction

In order to understand the functioning of a health system, one must identify its main elements and comprehend how they interact. It is the circulation of information that allows the different elements of the health system to operate in a co-ordinated way. Information is, as a matter of fact, an essential component of any technical or administrative action which takes place within the system.

In dealing with the issue of health information, two important aspects must be considered at the outset. In the first place, in order to be useful, the information which is necessary for technical or administrative decision-making must first have been collected, i.e., must exist, as such (a fact so obvious that should even dispense emphasis). Secondly, the information, to be useful, must also be readily available, so that it is in the hands of those who need it when they need it.

The main goals of this project are to improve data collection and information flow within the health system and to give quick access to appropriate information to all those who have decision-making responsibilities in the system, as well as to anyone who may need it or benefit from it. It is also hoped that, by achieving these goals, the project will also cause interaction among elements of the health system to improve.

This report describes the experimental phase of the project which has taken place in the past eight months in the city of São Paulo, Brazil, and the main conclusions derived from it, which have justified and oriented the expansion of the project.

II. Background

The State of São Paulo is the most populous and, from an economic point of view, the most important State in Brazil. Its economic growth, however, does not equally benefit all of its population, since there is a large number of people in the State who live in inadequate conditions, when not in absolute poverty.

The city of São Paulo, which is the capital of the State of São Paulo, has a projected population of 10.822.614 inhabitants for 1988, which is approximately one third of the State's total population. The capital city and 37 surrounding cities constitute the Greater São Paulo Metropolitan Area, with a total population of 16.454.422 people.

The State as a whole has 572 cities, 534 of which, with a population of 15.047.092, outside the Metropolitan Area. The projected population of the entire State for 1988 is, therefore, 31.501.504 inhabitants.

The public health system of the State of São Paulo is constituted by health units (hospitals, ambulatories, primary health care centers, laboratories, etc.) which belong to the government in any of its three levels: federal, state and municipal. Various kinds of agreements regulate the responsibilities of the three levels.

Administratively, the system is divided into 62 Regional Health Offices, which are grouped under five Co-ordinations. One such Co-ordination is responsible for the 15 Regional Health Offices in the Greater São Paulo Metropolitan Area, eight of which are located in the city of São Paulo itself. The Health Secretariat of the State of São Paulo co-ordinates and supervises the entire system.

III. The Necessity of Improving Epidemiologic Surveillance

The health system has so many needs, in the area of information, that it is difficult to list them all and, specially, to put them in a priority order. However, among the top priorities one could certainly mention the necessity of improving the epidemiologic surveillance system, in view of the major importance of communicable diseases as a public health problem, and considering that appropriate information is essential for their control.

Epidemiologic surveillance in Brazil is based on compulsory notification of cases of communicable diseases and has two main objectives:

- To detect, as early as possible, unusual disease patterns and, consequently, to trigger prompt disease control measures (immediate action surveillance system).

- To provide information on long-term trends in patterns of incidence and prevalence of communicable diseases, so as to support planning, policy-making and program evaluation (long-term action surveillance system).

Neither one of the two objectives is being satisfactorily achieved. Deficient and inefficient information flow are among the major reasons for that.

The Emílio Ribas Hospital is the core of the immediate action surveillance system, since it is the reference hospital for infectious diseases in the State of São Paulo, therefore drawing the largest portion of cases that require hospitalization. Besides reporting by mail to the Center for Health Information, the Emílio Ribas Hospital has to alert by telephone the intermediate level Regional Health Office in charge of the area where a particular patient lives, so that local control measures can be triggered. However, telephone communication with Regional Health Offices is an arduous task, because of insufficient and, therefore, always busy telephone lines. This hinders the effectiveness of the immediate action surveillance system.

Surveillance data to support long-term action are collected by primary health care centers and public hospitals, which send their reports by mail on a weekly basis. Underreporting, slowness in the information flow and inexistence of feedback to those who submit reports decrease the usefulness of the system.

IV. Objectives of the Present Project

The project basically consists in the establishment of a Videotex communication network in order to achieve the following objectives:

- To improve the epidemiologic surveillance information system, by establishing electronic data collection and transmission;

- To improve the utilization of information, by offering immediate electronic feedback to those who provide or collect data and to those who may benefit from, or otherwise need, this information.

- To improve communication among all elements and levels of the health care system, by giving them the option to use Electronic Mail facilities;

- To disseminate technical and administrative information to health professionals at the periphery of the health system.

V. Proposed Technology

Videotex was chosen as the technology for this project for the following reasons:

- Videotex's technical features, such as a built-in Electronic Mail service, its capacity of accessing data banks and the possibility of setting up pre-formatted questionnaires for data collection.

- Videotex's user-friendliness, which requires no specialized personnel for its utilization.

- Lower implementation and operational costs, when compared to alternatives.

VI. Pilot Project for the Evaluation of Technology

Since no previous utilization of Videotex had taken place in the health sector in Brazil, a pilot project was proposed in order to evaluate Videotex's potential, suitability and acceptability. The surveillance of infectious diseases in the city of São Paulo was chosen as the primary goal for the experiment.

1. Equipment:

Forty MSX microcomputers emulating Videotex terminals were rented from the local telephone company for approximately US$ 17 dollars a month. All applications developed were stored in the computers of the telephone company. A Videotex page composer was also rented.

2. Participants:

The terminals were distributed to users at the central, intermediate and peripheric level of the health system. At the central level, the organs of the Health Secretariat involved in the project are those which have responsibilities in the Epidemiologic Surveillance System (Center for Health Information, which co-ordinates the project, Center for Epidemiologic Surveillance, Center for the Control of Endemic Diseases, Emílio Ribas Hospital and its reference Laboratory, Immunization Division, Vaccine Supply Division, two reference hospitals and a few other departments). At the intermediate level, each one of the eight Regional Health Offices of the city of São Paulo are participating in the project, as well as a Community Health Department, which is an organ which belongs to the municipal health system of the city of São Paulo. At the peripheric level, 22 primary care centers are involved.

3. Human resources:

At the users' level, two professionals (with either High School diplomas or University degrees) of each unit were offered a two hour demonstration session on the operation of the system. These people transmitted the acquired skills to other colleagues.

At the central level, the implementation team is composed of two Medical Doctors (with no previous experience in Videotex), who are in charge of application development, and two technicians (familiar with Videotex programming) who are in charge of implementing and maintaining the applications.

VII. Applications Supported by the Network

The network was proposed as an optional communication and information tool. After connecting themselves to the public host computers, users can either access the Electronic Mail service or the Health Secretariat's menu, where all the information to be disseminated or questionnaires for collecting data are listed. The system supports general-purpose communications or the following specific routines:

a) Support to the Immediate Action Surveillance System:

The Emílio Ribas Hospital has utilized Videotex's Electronic Mail to alert Regional Health Offices on hospitalized cases of communicable diseases, allowing control measures to be triggered at the peripheric level. A copy of each notification is also sent to the Center for Epidemiologic Surveillance and to the Center for Health Information.

Electronic Mail has also supported horizontal communication among Regional Health Offices in order to transmit notifications among themselves, on behalf of other hospitals which do not possess a Videotex terminal (those which were not included in the pilot project).

b) Support to the Long-term Action Surveillance System:

Disease reporting through Videotex has been utilized on an experimental basis in order to allow comparison with the traditional, mail-based weekly reporting system. A version of the official questionnaire was adapted to Videotex and primary care centers agreed to notify by both methods so that the necessary evaluation could take place.

c) Information Feedback:

The Center for Health Information is responsible for storing data which are continuously collected by all health services in the State of São Paulo. These data provide the basis for the organization of a series of "Feedback Bulletins" open for public consultation through Videotex.

Epidemiologic data on the number of reported cases of diseases of compulsory notification are displayed in tables, histograms and maps. Detailed information on any disease can be obtained, as, for example, the number of cases occurring in each Health Region or in each neighborhood of the city, with weekly updating. Health units can, therefore, follow-up the temporal and spatial evolution of any disease, as well as compare their situation with that of other units or with figures of previous years, which are also provided.

Feedback bulletins providing mortality and demographic data are also available. Further information which is not displayed can be requested by Electronic Mail.

d) Delivery of Laboratory Test Tesults:

The Emílio Ribas Hospital has received by Electronic Mail the results of bacteriological tests performed in its supportive Laboratory, the Adolfo Lutz Institute. On an experimental basis, this application was limited to the diagnosis of meningitis, due to the disease's high incidence at the present time and due to the urgent need for more timely delivery of test results in order to introduce prompt therapeutic measures.

e) Dissemination of Technical and Administrative Information:

Technical bulletins organized by the Center for Epidemiologic Surveillance offer technical information on starting or current epidemics (meningitis, leptospirosis, dengue, AIDS), on new diseases (Brazilian Purpuric Fever), on surveillance procedures, on immunization campaigns, etc.

The Immunization Division collaborated with the setting up of a self-evaluation program on vaccines and with the selection of abstracts of scientific articles on immunizations.

The Health Secretariat's bulletin board, with announcements of meetings and congresses, extracts from official publications containing government acts and legislation of interest, service referral information, summary of important health-related news of magazines and newspapers, etc., is also available for consultation.

f) Other:

Electronic Mail has also been utilized to inform the Vaccine Supply Division of material to be delivered to Regional Health Offices, to schedule outpatient consultations or to contact physicians at the Infectious Diseases Ward in the reference hospital.

A drug utilization survey was implemented taking advantage of Videotex's data collection facilities (orientations on the survey were forwarded by Electronic Mail).

VIII. Discussion

1. Contributions of Videotex to the surveillance system:

Electronic Mail has been an effective means to improve communications among the Emílio Ribas Hospital and the Regional Health Offices, in support of the immediate action surveillance system. The reliability of this alerting system is assured, since all users at the central and intermediate levels check their Electronic Mail box at least once a day in order to retrieve existing messages and report back acknowledging receipt. It also enhances the interaction among the Center for Health Information, the Center for Epidemiologic Surveillance and decentralized surveillance teams in all Regional Health Offices of the city, since they can rapidly and simultaneously contact each other for technical and administrative purposes. Primary care centers can easily contact the organs of the Secretariat or their respective Regional Health Office to check receipt of notifications, request orientation on surveillance procedures, demand information on particular cases or complain when their requests are not considered, etc.

The daily observation of the network's operation regarding notification sources has provided interesting details on the behavior of patients within the health system. In fact, it demonstrated that, when patients believe that they have a more serious health problem, they bypass primary care centers, seeking medical care directly in hospitals. This was clearly evident during the occurrence of the meningitis and leptospirosis epidemics in the city. A large number of the notifications that were received every day was generated by the Emílio Ribas Hospital and not by the primary care centers in charge of the area where the patient lived. The primary health care centers would mostly report, instead, cases of chronic diseases.

This factual observation led to subsequent conclusions: since patients bypass primary care centers, information feedback is an important contribution to peripheric units. If this downward information flow does not exist, they cannot be aware of disease incidence in their region. The other expected contribution of Videotex, which was the timely receipt of notifications from primary care centers, was not proven very relevant, for they report mostly on chronic diseases, where urgent notification is not so crucial.

2. Considerations on acceptability and utilization:

Videotex's great user-friendliness allowed users with absolutely no knowledge of computers to easily master its operation. Its user-friendliness was fundamental towards the technology's high degree of acceptability and towards an effective introduction of information technology in peripheric levels of the health system.

Although Videotex was generally accepted, its utilization differed among users. Electronic Mail allowed an easy evaluation of users's participation in the project, according to their promptness in answering a given message. In general, 60% of the users would answer a message on the same day it was sent. 30% would have an irregular answering behavior, ranging from a prompt response to a five-day delay, and 10% of the users (all of them at the peripheric level) would answer just eventually.

Even though this criterion only measures one feature of Videotex -- its Electronic Mail facility -- other statistics kept on data collection and access to data banks show that the overall utilization pattern was basically the same.

An investigation into the causes of the low level of utilization in some primary care centers showed that the main causes were:

a) Very often, Videotex users could not connect themselves to the network, due to the fact that there was only one telephone line available in the unit, which was constantly busy for other purposes.

b) In order to induce a regular utilization of the system, Videotex would have to replace conventional ways of performing administrative routines. Since users were still obliged to do things in the conventional form, the parallel testing of Videotex meant working double, which was certainly not very motivating.

3. Considerations on Videotex's performance:

There was general agreement among users regarding the potential benefits of Videotex as an information and communication tool. They agreed on the fact that the project could and should be improved by exploring other routines (besides epidemiologic surveillance), by including other users in the network and by offering a broader range of information.

Videotex enabled the implementation of many applications, provided they utilized any of Videotex's technical facilities, such as Electronic Mail, access to data banks or data collection. Application development was fast and simple. "Pages of Information" were organized in a hierarchical structure that could be easily implemented, modified, removed or updated.

The most useful application of the network was considered to be Electronic Mail, which demonstrated to be an effective tool for the improvement of communications in the health system, enhancing vertical and horizontal information flow, promoting interpersonal as well as mass communication. It improved interaction among different elements and levels of the health system by allowing a new range of interconnections to be established, by speeding up information flow, by overcoming the communication bottleneck due to insufficient and always busy telephone lines, by allowing an immediate forwarding of written messages (which could be printed or kept as a record on magnetic media), by transmitting information independently of the presence of a receiving party at the destination point, etc. Information could be sent to specific users, being protected by passwords, or could be of general interest, being displayed on bulletin boards. Bureaucratic tasks could be simplified since messages written only once could be automatically forwarded to several different receiving parties.

Videotex also demonstrated to be an efficient way to provide information feedback to data providers and collectors, or to any one who uses the information. Constantly updated data could be easily displayed as tables, histograms, maps or plain text. Its impact on motivating users to collect data has not yet been evaluated.

The network also proved to be an efficient means to disseminate health information to geographically scattered users and to improve accessibility to technical information. It could be utilized as part of a distant continuing education program. Although it enables a far-reaching distribution of information, a new issue has arisen: who ought to determine the content to be diffused and who should provide it and maintain it?

Users considered Videotex a more pleasant and simple way to collect data. A disadvantage was mentioned regarding the fact that once the questionnaires were filled out and automatically sent, users would have no further access to it, not being able to edit it, as, for instance, to introduce late corrections.

4. General considerations:

Costs are certainly an important aspect in the utilization of computers in Brazil. However, the major obstacle towards a successful computerization of the health system has not been high costs, but the lack of appropriate human resources.

When considering a computerized communication network, the larger the number of users, the larger the benefit each user gets from the system. However, if the operation of such a network is to depend on specialized manpower, its impracticality is attested from the outset.

In this regard, Videotex has proven itself to be a specially suitable alternative to a standard, computer-based communications network, since it has almost no manpower implications.

Other aspect that should be emphasized is the low investment required for the implementation of a Videotex network. By investment one should consider not only hardware and operation costs, but also the human resources needed (in terms of quantity, skills and qualifications) and the time that is needed to implement the procedures. Videotex allows a very early production of benefits to users. Other technologies could bring greater benefits (in terms of power, precision and facilities), but at a much higher overall cost, and after a much longer span of time.

IX. Expansion

At the present time there are 56 users participating in the project. The expansion has included other tertiary hospitals in the city of São Paulo which are important sources of notification for the immediate action surveillance, the seven Regional Health Offices outside the Capital city (but within the Metropolitan Area), five Community Health Departments (which belong to the municipal health system of the City of São Paulo), other organs of the State Secretariat of Health, as well as a Medical School and a regional laboratory. Other primary care centers will be included in the project in the near future.

In addition, a dedicated, microcomputer-based Videotex host system was purchased and is being used in parallel with the host computer from the public telephone company, in order to offer a wider range of information to users.

X. Conclusions

The introduction of new information technologies in developing countries is a controverial subject. However, if the technology in case is utilized in the support of local needs and priorities, and if it suits the available human and financial resources, its introduction is certainly justifiable.

Videotex is a simple and viable alternative to implement a large scale, multi-purpose comunications network, requiring relatively low investments and having almost no manpower implications.

It allows a two-way information flow which enables a variety of specific and general applications. Its built-in Electronic Mail service improves the circulation of information in the health system, enhancing the interaction among different elements and levels within this system. Videotex also allows an efficient distribution of health information to geographically scattered users and the utilization of collected data as information feedback.

In view of this, Videotex is particularly interesting for those countries where human and financial resources are the major limitation towards the introduction of information technology.

(*) Paper presented at a Workshop at the World Health Organization, Geneva, Switzerland, August 1988

Last revised: May 02, 2004