We present the TSUs diagnostic evaluation, and the global diagnosis on their services maturity. Sixteen managers agreed to participate in the interviews complementary to the online survey. Their profile was female (75%), with an average age of fifty-three, ranging between 29 and 71 years. Regarding the professional training of leaders, medicine predominated (5), followed by nursing (3); computer science and dentistry (both with 2); and administration, biology, biomedicine, and psychology (all with 1).
TSU Diagnosis by Theme
The survey mapped the activities according to the theme structure, and management. TSUs offer teleeducation (16/17), asynchronous inter-consultation (14/17), and telediagnosis (12/17), via specialists integrated into the National Telediagnosis Platform. Teleconsultation (10/17) had the lowest number of offers. Health promotion activities are offered as support to the lines of care (13/16). Most TSUs are integrated with referrals to social assistance support and support epidemiological surveillance (9/16). They (13/16) are formally included in an institution's organizational structure and have an organization chart for telehealth (9/16). The services cover primary, chronic disease, outpatient, and mental health care. Attention to indigenous health, and people with disabilities care is provided in three units.
According the second theme, financial and budget management, 11/17 TSUs have a financial plan. On average, 53% of TSUs direct costs are allocated to salaries or remuneration per activity of the permanent team. Other costs include fellowships (20%), physical facilities (10%), maintenance of services (7%), and services (9%). Monitoring and evaluation using financial situation indicators are conducted (8/13). Cost-minimization (4/13) and utility cost (3/13) indicators are used.
For processes and activities, units had established flows, protocols, and clinical guidelines, even in the form of good practices (6/15). Regarding the patient consent, TSUs (16) receive consent forms electronically through electronic registration platforms for teleconsultation (8/16), telediagnosis (6/16), and asynchronous (4/6) and synchronous (3/10) inter-consultation. Verbal approvals or no consent still occur in 2 to 5 TSUs. TSUs claimed to have procedures for mapping the average time required to solve technical problems (14/16). Thirteen TSUs have a contingency plan for equipment and connectivity failures. The existence of standardized procedures for communicating incidents was rated as satisfactory by 9/16 TSUs.
About human resources, the profiles are teleconsultants (603), IT professionals (110), administrative assistants (97), teleregulators (33), technical-scientific researchers (30), general coordinators (19), education professionals/EAD (18), digital health professionals (18), specialists in artificial intelligence or data analysis (6), monitors (6), field coordinators (6), and digital law specialized attorneys (3). Three groups (G1, G2, and G3) and one distinct TSU were observed when the average workload of the permanent team was related to the number of professionals in the direct team of the TSUs (Fig. 2).
G1 is composed of TSUs with smaller teams and workloads, with an average of two hours a day. G2 comprises TSUs with teams comparable to G1 but with an average daily workload of approximately four hours. G3 is composed of TSUs with large teams but the lowest workloads. Most TSU offer team training (13/14). Training is conducted through documentation in 8/13 of these TSUs. They (11/14) have teams sufficiently qualified. Two TSUs indicated an insufficiency of professionals.
TSUs have permanent education policy (6/14) according to the responses to the theme training, and outreach. Emerging issues were continuing education in data protection rules (9/14), and security (10/14). Two-thirds of the TSUs offer training to requesting professionals (10/15).
Regarding the theme infrastructure and technology, the TSUs have an exclusive space for the secretariat (10/14) and an environment for the teleconsultant (9/14). Two-thirds use platforms developed locally (10/15). Most TSUs (9/15) use an integrated electronic health record (EHR-S) system, including EHR-S with the SUS’s clinical history (4/15) and registration (4/15); (9/14) units consider their storage space for the next two years satisfactory. There is a proper budget line for the administrative functions, a formal support in financial control and an appropriate line for the maintenance and acquisition of equipment and software in all TSUs. Additionally, noteworthy is the standard support for the needs of the data centre and its high performance (14/15).
For the monitoring and evaluation theme, the TSUs automatically monitored services (52%) and complementary manual assessment. Most TSUs account for municipality activities such as teleconsultation (13/17), inter-consultation (8/17), telediagnosis (9/17), and teleeducation (12/17). In addition, the TSUs reported counting by unit served, specialty, team, state of the federation, and synchronous versus asynchronous activities. The practice to conduct a satisfaction survey was undertaken (8/14). Only 3/14 TSUs conduct long-term opinion polls. The most frequent difficulties reported were the inadequacy of the hiring modality and funding discontinuities (8/14), high turnover of professionals and managers in the municipalities (5/14), and low profiles in TSUs and municipalities (3/14). One TSU reported the lack of a national platform with standardized services and poor connectivity quality.
The leaders engage with the team and professionals at the health centres served (12/13) according to the acceptability and suitability theme. Engagement with citizens/patients almost did not occur (3/13).
In protection and security, most TSUs claimed to record consent forms regularly for services (8/13); only a handful reported doing so in an incipient way (3/13), and 2/13 claimed that the process is not conducted. In 8/11 TSUs, there is a guarantee from the host institution in the strategies implemented to monitor the reliability of the data.
The TSUs maintain the confidentiality of the data provided (12/14), according to the responses to the topic ethical and legal aspects. The processing personal data comply with national regulations in 9/14 of the TSUs.
For innovation and research network’s theme, TSUs have formal link with research sectors (12/13); in 9/13 TSUs, there is a research department. According to the scenario regarding the TSUs’ participation in the National Health Data Network (RNDS), one unit reported full participation in building the RNDS data repository, and 3/14 TSUs with incipient participation. Considering health surveillance, 4/14 of the TSUs reported satisfactory integration between the RNDS, the app Conecte SUS, and the host institution in COVID-19 care procedures.
Planning is linked to the sustainability of TSU actions (12/14), according to the 12th theme, citizenship, and sustainable development. The MoH finances 11 of the 15 TSU; in seven, the MoH is the sole or significant funding source. Seven TSUs reported other primary funding sources. To achieve ways to promote citizen participation, they do EAD courses (4/14), advertising campaigns, webinars, and video channels (8/14).
Global Diagnosis
We generated a radar chart for 15 units, presenting the TSU diagnostic evaluation, that allows a visual comparison of the interpreted results against the mean (Fig. 3). A percentage value represents the indicator for each of the twelve themes. The darkest area represents results above the TSUs means, while the other area represents results below the mean.
There were two assessment types: the respondent's self-assessment and the researchers' diagnostic assessment. The data collected refer to the services’ description and the level of maturity assessed by the TSUs.
Global results show the self-assessment of maturity as reported by respondents, the diagnostic evaluation produced throughout this study, the difference, and the group in which the TSUs were labeled based on the analysis of Groups M1, M2, and M3 that contextualize the maturity profiles (Table 2).
Table 2
Self-assessment (%) and diagnostic assessment (%) comparisons
# | TSU | Evaluated topics | Self-assessment (13 topics) | Diagnostic assessment (34 topics) | Difference | Group |
1 | 1 | 34 | 38% | 39% | 1% | M3 |
2 | 2 | 34 | 51% | 49% | -2% | M2 |
3 | 3 | 34 | 33% | 35% | 2% | M3 |
4 | 4 | 34 | 51% | 55% | 4% | M2 |
5 | 6 | 31 | 62% | 48% | -14% | M2 |
6 | 7 | 26 | 62% | 34% | -28% | M2 |
7 | 8 | 34 | 46% | 57% | 11% | M2 |
8 | 10 | 34 | 82% | 62% | -20% | M1 |
9 | 11 | 34 | 64% | 57% | -7% | M2 |
10 | 13 | 33 | 90% | 57% | -33% | M1 |
11 | 14 | 34 | 87% | 78% | -9% | M1 |
12 | 15 | 34 | 59% | 56% | -3% | M2 |
13 | 16 | 21 | 44% | 25% | -19% | M3 |
14 | 17 | 25 | 44% | 32% | -12% | M3 |
15 | 19 | 33 | 85% | 56% | -29% | M1 |
| | | 60% | 52% | | M1:4 TSU M2:7 TSU M3:4 TSU |
The relationship between the self-assessment and the diagnostic assessment was measured (Fig. 4).
It is possible to observe the presence of three TSU groups concerning the maturity level assessment (maturity groups, M):
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M1: high; units that have an increased maturity regarding telehealth services, showing stability in the services’ offer and the projects’ participation.
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M2: intermediate; units whose telehealth services are already at a reasonable level, have room for improvement, and have valuable experience in the relationship and exchange of services with other TSUs.
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M3: low; units that present a level of lag in services, with a significant margin to evolve with the potential to form a network of services.
The groups’ interpretation should be made with the self-assessed and diagnostic assessment presented and Table 2. TSUs 7, 16, and 17, which had fewer assessed topics, were the ones that presented the most significant discrepancy between the self-assessed maturity level and the diagnostic assessment maturity level. This caused TSUs 16 and 17 to be grouped in the M3 group. TSU 7, on the other hand, was placed in the M2 group due to its higher level of self-assessment. This does not necessarily mean that the telehealth services of these TSUs are nascent. Instead, the final evaluation had interference due to the lack of completeness of the topics and that the unit has potential for improvement.
On the other hand, the TSU who responded to all topics had a greater tendency for self-assessed maturity levels and diagnostic assessment to be close. It is worth highlighting TSU 1 and 3, which remained in the M3 group but are new or have some level of difficulty in providing services; thus, they have a large margin for evolution. TSUs 10, 13, and 19 were placed in the M1 group. They had a high self-assessment level but a more significant discrepancy for the diagnostic evaluation.
For the M1 group, in which each TSU has a high maturity level concerning telehealth services, we can observe that from the four TSUs, only two (10 and 14) have a self-assessment, like the diagnostic assessment. The two TSUs in M1, which present a discrepant self-assessment from the diagnostic evaluation, have a difference that exceeds more than 30% in both units. For the M2 group with an intermediate maturity level, which has a total of seven TSUs, we can highlight that three have self-assessments that converge on the same maturity levels of the diagnostic assessment (2, 11, 15). Three TSUs in M2 (4, 6, 8) had a gap between the maturity levels presented in the self-assessment and the diagnostic assessment. In the M3 group with low self-assessment and diagnostic evaluation for maturity level, two TSUs (1 and 3) have maturity levels that converge on those of the self-assessment and diagnostic assessment, thus showing little difference between the two assessment processes. The other two TSUs in M3 (16 and 17) have discrepant maturity levels between the two assessments.