A single-center study following the guidelines “Evaluating digital health products” from Public Health England [17], with local adaptations for the project and the Brazilian reality, was conducted between São Paulo and Santarém in Brazil.

A descriptive study of the “analysis of routinely collected data” [18] using administrative and “user feedback study” [19] data collected by a satisfaction survey was conducted by the management team.

This user experience study was approved by the ethics committee of Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paul Comissão de Ética para Análise de Projetos de Pesquisa) without the need for ethical analysis by the research ethics committee system (Comitês de Ética em Pesquisa/Conep). According to the guidelines of Brazilian National Health Council resolution No. 466/12 and No. 510/16, studies that only have the objective of assessing a service for the purpose of its improvement or implementation, which do not aim to obtain generalizable knowledge but only data that can be used by that service for its improvement, do not require ethical analysis by the research ethics committee system (Comitês de Ética em Pesquisa/Conep), as it does not have direct patient involvement or handle personal data [20,21].

In this study, a satisfaction survey was carried out among patients, and an opinion survey was given to physicians. All responses were collected anonymously, without identifying or sensitive data.

All the data collected were used to evaluate the performance of the pilot project carried out between September and December 2021 to identify possible points for improvement, such as internet connectivity and patient satisfaction.

What is the satisfaction of patients regarding teleconsultation between São Paulo and Paysandú?

From September 27 to December 15, 2021, a study was carried out linking a basic health unit in the city of Santarém and a university hospital in the city of São Paulo, separated by about 2500 km. The basic health unit is located in Paysandú District, a riverside city in the city of Santarem, state of Pará, Brazil. The local team consists of 1 nurse and 2 nursing technicians.

For remote medical care, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, a tertiary university hospital, hired a primary care physician for 20 hours per week (5 hours per day, 4 days per week on Monday, Tuesday, Wednesday, and Friday afternoons), totaling 39 days with 195 hours scheduled for appointments and 220 hours performing teleconsultations (Table 1).

Disregarding holidays, local vaccination campaigns, and justified absences of the hired doctor when there were no remote appointments during the project, there were 220 performed consultations (Table 1).

To assess the performance of telemedicine, at the end of each consultation, the doctor fills out a multiple-choice survey based on their personal opinion through a Google Form on the administrative aspects of care.

To simplify the administrative analysis, the consultation performed was classified according to the following criteria by the doctor:

At the end of each medical consultation, a health agent asked whether the patient was interested in participating in a satisfaction survey anonymously. If the patient agreed to participate in the survey, a self-explanatory printed satisfaction survey in Brazilian Portuguese with multiple-choice questions using a Likert scale was given to the patients, with the following response options:

The questions used in the satisfaction survey (translated from Portuguese):

The data from Google Forms were extracted to Excel version 2010 (Microsoft Corporation), where they were analyzed.

A pilot project of telemedicine was built to connect a metropolitan city, rich in human resources and infrastructure, to a riverside city in the middle of the Amazon region, where the only possible physical access is by boat and the internet is provided by satellite. Before this pilot project, the local population of the district Paysandú received one medical visit a month from the city of Santarém, with 30 appointments scheduled for 1 day. When there is an unscheduled spontaneous demand, a 6-hour boat ride downtown is needed.

The pilot project provided the local population with one web-based physician 4 times per week; during the 12-week period, 220 consultations were offered (an average of 73 consultations every 4 weeks). Considering the infrastructure connectivity shortcomings, there was no need for the doctor of the city of Santarém to travel to the district of Paysandú for local consultations. To reduce subjective bias, only one clinical physician was hired to evaluate the conditions provided for telemedicine, like other studies involving technologies [22].

As described by Combi et al [23], implementing telemedicine in low-income countries has more challenges than in high-income countries. So, there are several relevant findings from the feedback from the hired clinical physician.

First, the web-based doctor did not need the support from a local doctor, which means that a permanent telemedicine program is possible in this region. Second, only 0.9% (n=2) of the teleconsultations had no connectivity issues, a recurring problem in remote regions such as Amazonas [23]. Even with signal problems, the presence of the doctor at a distance is useful for the local population, as will be discussed below. Third, 90.1% (n=200) of teleconsultations needed a local support team and relevant information regarding setting up a health care unit in remote regions, requiring the presence of a local health agent.

In addition to being effective, the telemedicine service also needs to be well accepted by patients [24,25], even with connection problems in more than 99% of teleconsultations. More than 95% of the survey participants were satisfied with the received health care, especially in relation with the doctor, the infrastructure (even with the existing connectivity problems), and the support of the local team. This percentage was probably directly influenced by the high percentage of patients who were familiar with the use of telemedicine [23]. However, it is noteworthy that 76.6% (n=85) of patients responded that they had their needs answered by the doctor during the teleconsultation (Table 7) using only a videoconference camera, which indicates that telemedicine helps substantially, but it still does not replace face-to-face care in full, and barriers still need to be overcome [26].

To avoid bias from different doctors in the performance of the consultations, all appointments were performed by a single hired doctor, which had the limitation of medical impressions being from a single source.

Additionally, because there was only one doctor in the study, the high rate of satisfaction may be due to the role played by the hired doctor; on the other hand, the high rate of satisfaction also suggests that a good doctor-patient relationship increases patient satisfaction even with medical care at a distance and scarce resources.

No evaluation was made comparing this visit with the previous monthly medical care visit, so it is not possible to assess whether telemedicine was better accepted in relation to previous medical care.

As this was a user experience study based on satisfaction and opinion, no clinical data were collected or evaluated; so, there is no way to assess the clinical effectiveness of telemedicine, only its acceptance by the involved users.

This teleconsultation project between São Paulo and Paysandú showed that it is possible to offer medical care from more developed locations to communities far from urban centers.

Beyond the feasibility of the infrastructure, acceptance and satisfaction among patients was high. This remote health care model proves to be functional and should be expanded nationally or perhaps internationally to regions lacking medical care. Escalation of the project does not seem too difficult once infrastructure issues are solved.

Having the possibility of offering medical care with professionals at a distance, it is possible to design a future where members of a small community can go to urban centers in search of medical education and, after completing their graduation, serve their home population through telemedicine.

In addition to the possibility of using remote monitoring devices, such as smart watches [27], the potential for improving the quality of health care for populations in need of medical care is promising.