The structural barriers should be the target of hospital managers. Development of standard remote care protocols may increase the use of telemedicine and create new work routines. Given the relationship difficulties among the RU and HT doctors during telemedicine consultations, other meetings should be organized to allow more interpersonal interactions. These meetings may also have the goal of sharing outcome indicators of their joint activity in telemedicine to stimulate and make them aware of the benefits of their interaction.

Objective To describe the impact of the telemedicine application on the clinical process of care and its different effects on hospital culture and healthcare practice.Methods The concept of telemedicine through real time audio-visual coverage was implemented at two different hospitals in São Paulo: a secondary and public hospital, Hospital Municipal Dr. Moysés Deutsch, and a tertiary and private hospital, Hospital Israelita Albert Einstein.Results Data were obtained from 257 teleconsultations records over a 12-month period and were compared to a similar period before telemedicine implementation. For 18 patients (7.1%) telemedicine consultation influenced in diagnosis conclusion, and for 239 patients (92.9%), the consultation contributed to clinical management. After telemedicine implementation, stroke thrombolysis protocol was applied in 11% of ischemic stroke patients. Telemedicine approach reduced the need to transfer the patient to another hospital in 25.9% regarding neurological evaluation. Sepsis protocol were adopted and lead to a 30.4% reduction mortality regarding severe sepsis.Conclusion The application is associated with differences in the use of health services: emergency transfers, mortality, implementation of protocols and patient management decisions, especially regarding thrombolysis. These results highlight the role of telemedicine as a vector for transformation of hospital culture impacting on the safety and quality of care.

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Objective: To characterize variables associated with referral to the emergency department following Telemedicine consultation during the COVID-19 pandemic. Methods: Cross-sectional retrospective study conducted between March and May 2020, with a sample of 500 adult patients. The inclusion criterion was the manifestation of respiratory symptoms, regardless of type. Results: The mean age of patients was 34.7±10.5 years, and 59% were women. Most patients (62.6%) perceived their own health status as malaise and some (41.4%) self-diagnosed COVID-19. Cough (74.4%), rhinorrhea (65.6%), sore throat (38.6%) and sneezing (20.6%) were the most common infection-related symptoms. Overall, 29.4% and 16% of patients reported dyspnea and chest pain, respectively. The Roth score was calculated for a sizeable number of patients (67.6%) and was normal, moderately altered or severely altered in 83.5%, 10.7% and 5.6% of patients, respectively. The percentage of suspected COVID-19 cases was 67.6%. Of these, 75% were managed remotely and only one quarter referred for emergency assessment. Conclusion: Telemedicine assessment is associated with reclassification of patient's subjective impression, better inspection of coronavirus disease 2019 and identification of risk patients. Referral is therefore optimized to avoid inappropriate in-person assessment, and low-risk patients can be properly guided. Telemedicine should be implemented in the health care system as a cost-effective strategy for initial assessment of acute patients.

Background: The coronavirus disease 2019 (COVID-19) pandemic led to the suspension or postponement of care for nonurgent conditions worldwide. Regula Mais Brasil is an initiative of the Unified Health System (SUS) in Brazil to optimize the management of referrals to specialized care by using telehealth. Objectives: To report the expansion of telehealth activities of Regula Mais Brasil in response to COVID-19 and to assess qualification of referrals in primary health care (PHC) units as well as the added value of teleconsultation in qualifying referral cases. Methods: Descriptive study of the teleconsultations carried out as an additional strategy to the remotely operated referral management system, responsible for navigating cases from PHC units to specialized care in Recife, Brazil, between May 6, 2020 and September 30, 2020. Teleconsultation was implemented as a tool for reducing delays in the access to health care due to COVID-19 and ultimately allowed for reclassification of the referral ade-quacy and priority. Changes in referral priority ratings and referral decisions after teleconsultation were analyzed. Results: A total of 622 referral cases were analyzed. Approved referrals represented 51.9% of cases. The main reason for approved referrals was the need for diagnostic resources. There was a reduction in priority ratings in 449 cases (72.2%) after teleconsultation. There was a statistically significant association between the change of priority ratings and the decision on referral (Pearson's v 2 , p-value <0.0001). Results show that telemedicine had an impact on the prioritization and qualification of cases referred to specialized services. Conclusions: A need was detected to rapidly adapt tools available for telemedicine in Brazil. Our results demonstrate that teleconsultation as an additional strategy to the remotely operated referral management system has contributed toward improving equitable access to specialized services.