Brazil is a vast country of marked cultural, economic, geographic and infrastructural contrasts. It is composed of 27 federative units: 26 states and one federal district that contains the capital, Brasilia. Although the Brazilian Constitution guarantees universal and equitable access to high-quality health care, these contrasts make such access difficult to provide. Primary care is central to Brazil's public health system, which aims to provide comprehensive health care, specialized services and hospital care, as well as health promotion and disease prevention activities. (1) Minas Gerais, a large state, has 19 million inhabitants unevenly distributed among 853 municipalities and is characterized by inequities in health care. (2)
Residents of small and remote municipalities have difficulty accessing specialized care because health resources are concentrated in the largest cities. Health professionals in remote areas tend to be young and inexperienced and are often isolated and in need of further training. The resulting high turnover rates in the primary care workforce compromise service quality. This, plus the small amount invested in linking primary care with other levels of care and the failure to provide good access to diagnostic tests, prevents the Brazilian primary health-care model from fully meeting its objectives. (1)
Telehealth, or the use of information technologies in the health professions to provide care, impart education or conduct research, has the potential to reduce existing health-care inequities by supporting primary care professionals in remote areas. (2-4) Telehealth offers an effective means of improving communication between primary care practitioners and specialists in reference centres, facilitating access to diagnostic tests and enhancing health care quality in under-served communities. (2,5) However, little information is available with respect to cost-effectiveness, access to services, process of care and user satisfaction in connection with telehealth. (5)
In 2005, the State Government of Minas Gerais, Brazil, funded the establishment of the Telehealth Network, designed to connect the teaching hospitals of five public universities with municipal health departments. (6) The health department of the state initially implemented the programme as a research project in 82 municipalities with fewer than 10 500 inhabitants. Because cardiovascular diseases are the leading cause of death in Minas Gerais and remote areas have a serious shortage of cardiologists, the state health department decided to focus the project on telecardiology [Minas Telecardio Project], (6) specifically on tele-electrocardiography (i.e. the use of the internet to send electrocardiograms [EKGs] from remote areas to university hospitals for interpretation). The project proved feasible and financially sound (6-8) and satisfaction among physicians working in remote locations increased markedly. (9-10)
After 2007, the Telehealth Network of Minas Gerais began providing teleconsultations also. In other words, primary-care professionals began using the network's web site to address questions to university staff in areas such as medicine, nursing, dentistry, physiotherapy, nutrition, pharmacy, psychology and audiology. Primary-care professionals can thus perform their clinical activities with the support of a network of specialists on duty in the universities. The specialist who first answers the teleconsultation can seek the help of a subspecialist if s/he considers it necessary. This service is viewed as an ongoing educational tool, since every teleconsultation represents a learning experience. The network was progressively expanded and had reached 608 municipalities by August 2010.
The Telehealth Network relies on low-cost technical equipment easily accessible to poor villages: computers, printers, digital electrocardiographs, digital cameras (e. …