At the end of last year and beginning of this, when the late governor Mário Covas was hospitalized at the Institute of the Heart (InCor- Instituto do Coração) of the Hospital of the Clinics of the School of Medicine of the University of São Paulo, not only the doctors going in and out of the place where he was were taking part in his treatment. The governor’s case, complex and involving several medical specialties, set doctors into motion even at the Sloan-Kettering Cancer Center, in New York, United States. Using a system of teleconferencing, doctors from InCor and Sloan-Kettering and members of the family had long discussions on the case and on the possible ways of treating it.
Hearing a second opinion is not a novelty, nor does it mean that the doctors looking after the governor in São Paulo felt unsure of themselves. It is common practice, especially in the more serious cases. In this case, the novelty was that the consultations took place without the governor having to travel to New York, nor even to leave his sickbed in São Paulo. Conferences like this one are part of the so-called telemedicine, a set of resources based on information technology that is altering the practices and usage in various sectors of medicine and that is gaining ground, as computer networks grow and are perfected. Nor are they a privilege of important politicians. Provided there is someone to meet the cost, the same systems as those used by Covas are at the disposal of everybody at InCor.
It is not by chance that the system is available at Incor. This institution was one of the pioneering hospitals in Brazil in the implementation of computer networks. InCor’s first network goes back to 1980. “But the big leap forward happened in November last year, when an increase in the capacity of the network, put into practice with the help of FAPESP, made it possible to create the teleconferencing system”, explains Umberto Tachinardi, the director of InCor’s Information Technology Service Systems Unit. It is not the only novelty that is making its appearance at the institute. The online case history system, now at the installation stage, will allow anybody with access to a network computer to check all the details collected on a patient, from his registration details to the latest examination.
Benchmark
The numbers are impressive. In the year of 1999 alone, InCor attended to over 230,000 patients, and carried out more 1.5 million examinations, laboratory tests and diagnoses from images. This demands an enormous network capacity, which could hardly have been achieved without the help of FAPESP. There are other factors in play. As a benchmark for cardiology in Brazil, InCor has the mission of disseminating knowledge generated in-house and of seeking information from other institutions in the same area. This has always been done, through lessons, courses, seminars, workshops, and even videotaped surgical operations. “With the teleconferencing connection, this can now be done at a distance, which will be of particular benefit to those professionals who work outside the major centers”, says Tachinardi.
And that is not all. In the intensive care units, the monitors that keep a watch on all the vital functions of the patients, such as their heartbeats and blood pressure, have been connected to the network. The doctor in charge can now, for example, check, from any computer in the hospital, if the medicine to correct an irregular heartbeat has had the desired effect. At first, the routine changed little. The doctors continue to visit their patients three or four times a day. “The difference is that today I can keep a better eye on how the situation of each patient is developing” says Carlos Vicente Serrano, a clinical cardiologist.
The benefits of the system for a hospital like the InCor, where the preservation of life often depends on swift action, are enormous. Serrano tells about a situation that has already become part of his routine. The blood pressure of a patient who is seriously ill drops, which, in the shape that he is in, may be fatal. The doctor medicates him, and, half an hour later – the time needed for the medicine to take effect – consults the patient’s monitor and checks his situation.
If the pressure is back to normal, he will continue to monitor the case by the computer. If not, he will send a message by the computer to the ward, indicating the steps to be taken. A warning signal warns the ward when the message arrives. “The action becomes much more rapid and efficient, and, in addition, the doctor’s time is optimized,”, Serrano comments.
Less traumas
The process is still at the beginning, but InCor’s researchers are also taking the first steps in a new technology: using the network to carry out operations at a distance. The method uses a robot controlled by a surgeon, and it is already being used in Europe. It is regarded as more efficient, and it causes the patient less traumas, in some cases, than ordinary surgery. InCor has decided to train its firepower on a relatively modest project. Contrary to the robots manufactured by some foreign laboratories, the São Paulo project will not have three or four arms, to hold and manipulate the surgical instruments. It will have just one arm, to do the job of the assistant surgeon who handles the optical system, the camera used in the operations.
In this kind of surgery, the cuts are very small, just big enough to introduce the instruments into the body of the patient. The surgeon works on the basis of the images captured by the optical system, which are transmitted to a computer screen. One of the biggest advantages of the system is that it allows the patient to recover more rapidly. “In a cardiovascular operation, like a conorary bypass, the patient can go home on the following day, while under the traditional method he would have to stay in hospital for between a week and ten days”, says Fábio Biscegli Jatene, one of InCor’s surgeons.
The robot project is being developed by InCor’s Bio engineering division, in partnership with USP’s Polytechnic School, with funding from FAPESP. Idágene Cestari, InCor’s director for research in Bioengineering, states that the system can be used in any surgical operation, not just in heart surgery. Jatene, who has already tried out the technique in a Dallas hospital, supports the approach that has been adopted. “I think that, at this moment, it is more worthwhile to invest in a modest project than to spend piles of money to import a more sophisticated robot”, he states.
Over 36,000 pages
At São Paulo Federal School of Medicine (Unifesp) , the emphasis is on teaching at a distance. Since 1992, when the network started to be implanted, teachers and specialists in IT have been working together to draw up courses in various disciplines. The result is one of the most complete websites in the area of health on the Internet. Unifesp’s site has no less than 36,000 pages, which range from information on projects and courses to complete courses and didactic support material, with over 450 lessons in video. The site receives between 8,000 and 9,000 accesses a day, of which 3,000 are from outside the network.
Not all the courses at a distance have a direct connection to classes. One of the courses with the biggest repercussion is the one that simulates disasters, organized in partnership with the Hospital of Clinics. Its purpose is to train health professionals to act in catastrophe situations. It has 3,800 registered students, among doctors, nurses and professionals from the fire brigades of several cities, who receive lessons from specialists over the Internet. As part of the course, the pupils are given videotapes they can watch at home, at any time.
Daniel Sigulem, the head of Unifesp’s Department for Information Technology in Health, notes that, for the school, this also means savings. “We have developed a system that has the result of doing away with the use of the laboratory in the Histopathology course”, he comments. “The slides are now seen in the computer, instead of in a microscope, with the same effect for the students”, he says. Nevertheless, not everything went in accordance with the expectations of the organizers. At the beginning, they thought that a teacher could look after up to 500 students with the new methods. Wrong. The limit is between 20 and 30. There was much more interaction between teacher and pupil. In a conventional lesson of 50 minutes, the student normally has just the last ten minutes to raise questions. Now, contact with the teacher, by e-mail, is never-ending.
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