Entrevistador: Lic. José Antonio Paredes C. (JAPC).
Entrevistado: Dr. Ramiro Vaca Narvaja (RVN), Coordinador del Departamento de Telesalud en la Clínica Pasteur Neuquén en Argentina. Médico especialista en Terapia Intensiva. Master en Informática en Salud (en curso), Master en Cuidados Críticos, Postgrado en Recuperación Cardiovascular, Postgrado en Cardiología, Ex docente de la Universidad Nacional del Comahue (Cátedras de Fisiología y Entornos Virtuales), Co-fundador y Director Médico T-Maider.
En esta entrevista analizamos desde su perspectiva y experiencia los retos que tenemos en América Latina en el crecimiento y fortalecimiento de la telesalud y de la salud digital, además de los pasos decisivos llevados a cabo en esta época de pandemia de coronavirus en la región.
JAPC: Agradezco al Dr. Ramiro Vaca Narvaja que nos haya permitido tomar unos minutos de su tiempo para realizar esta entrevista para nuestros lectores en América Latina, donde abordaremos temas de telesalud desde su experiencia y opinión.
RVN: Buenas tardes José Antonio, es un placer poder conversar contigo de esta temática tan importante como lo es la Telesalud; muchas gracias por la invitación.
JAPC: ¿Cómo médico porque se inclinó en el uso de las tecnologías en apoyo o complemento a la atención médica como una herramienta, de donde el gusto o pasión por ello?
RVN: La incorporación de tecnología a la vida cotidiana es innegable, tanto en la esfera personal como en cualquier ámbito profesional, y la salud no es una excepción. Es fundamental evolucionar y adaptarse a los nuevos paradigmas que nos plantea este nuevo siglo en el que los avances en desarrollos tecnológicos se suceden a velocidades exponenciales, y es probable que esto se acentúe aún más en los años venideros.
Sortear las barreras que genera la incertidumbre de un cambio de semejante magnitud me presenta un desafío emocionante e irresistible; y que, como parte de una generación, tan vigente como saliente, siento la responsabilidad de llevar la posta lo más lejos posible y allanar el camino para el desarrollo de las generaciones que vienen detrás.
JAPC: ¿Cómo puede la Telesalud mejorar la vida de los pacientes?
RVN: En beneficio de los pacientes podemos identificar dos ejes de máxima relevancia, en primer lugar, la accesibilidad y en segundo lugar el tiempo.
La accesibilidad es clave para la sustentabilidad de un sistema de salud cada vez más demandante y que prolonga su periodo de asistencia mucho más allá de lo imaginado hace no un mucho tiempo atrás. En este sentido la Telesalud, en todas sus aristas, brinda la posibilidad, mediante la Telemedicina, de acceder a profesionales y especialistas, antes distantes, desde gran parte del planeta y desde la gran mayoría de los dispositivos electrónicos vigentes; mejorando la calidad de asistencia y garantizando continuidad de seguimiento para los pacientes.
El tiempo, gran tirano, es tal vez lo más preciado y su consumo, irreversible e inevitable, es un tesoro en reserva que se nos fuga entre las manos como el agua; y es por esto que la optimización de los tiempos de gestión de turnos y estudios, disponibilidad de resultados, espera en sala preconsulta, y reinserción en la agenda personal postconsulta, toman un valor dimensional incalculable, sin contar los potenciales beneficios de chances de tratamientos, y por ende de morbimortalidad, que de un diagnostico precoz derivan. Mediante la incorporación de asistencia a distancia, en diversas modalidades, reduce de manera significativa el consumo innecesario de esos minutos tan preciados para la vida de todos.
JAPC: ¿Cuáles son las tendencias en temas de salud digital, desde su punto laboral o de experiencia?
RVN: En estos momentos es imperioso forjar un marco regulatorio legal de todos los procesos involucrados en Telesalud. La dispersión de sistemas y políticas de salud a nivel mundial, y por supuesto el posicionamiento de los países latinoamericanos, es muy basto y complejo, y en este escenario resultara una tarea más que difícil encontrar un “norte” unificado. Cada país está redactando las reglas jurídicas y de seguridad informática que considera pertinentes, y en este punto al menos Argentina, está bastante avanzado en relación a otros países de su mismo estatus económico y social.
Sin embargo la tendencia actual está enfocada a uno de los puntos más relevantes para la masificación de la implementación de telemedicina como moneda corriente, y es la firma digital, que no solamente debe involucrar la certificación de identidad personal, ya instalada desde hace varios años, sino que además deberá agregar sellos de competencia que involucren los avales profesionales y sus respectivas legislaciones que también incluyan la vigencia de ejercicio y certificación de especialidades. Y es este el punto cuello de botella para que la fluidez de indicaciones, solicitudes y recetas llegue a los efectores y a su vez los financiadores puedan dar cobertura y auditoria.
JAPC: ¿Cuánto tiempo lleva trabajando en temas relacionados con la Telesalud – Telemedicina?
RVN: Comencé a incorporar información y conocimientos en temas de Telesalud en 2016 y no fue hasta el 2018 en el que efectivamente inicié los proyectos de trabajo más que nada en Telemedicina, fundando una empresa que tenía como objetivo la asistencia en áreas remotas ligadas a la actividad petrolera.
En el 2019, un año antes de la inesperada pandemia, comenzamos con un proyecto institucional de la Clínica Pasteur de Neuquén, que, con gran visión, tomo la determinación de apostar al desarrollo de una plataforma de telemedicina con todos los estándares necesarios para asegurar solidez y eficiencia para la atención de sus pacientes. En este sentido, cabe aclarar que la piedra fundamental de cualquier proyecto en Telesalud requiere de un compromiso direccional y exclusividad departamental para no naufragar en el intento, y aprovecho para agradecer la confianza que la Clínica ha depositado en mí para liderar el proyecto y sobre todo en aquel momento, que parece tan lejano pero que fue hace solo un puñado de meses, en el que incluso teníamos que explicar el significado de la palabra “telemedicina” ante un auditorio de ceño fruncido y que muy poco tiempo después se transforma en terminología habitual de voz populi.
JAPC: ¿Cuáles son los beneficios de la telemedicina durante la pandemia de COVID-19?
RVN: No creo que podamos dimensionar aun los beneficios que ha ofrecido la telemedicina durante la pandemia de covid. Solo podemos analizar las experiencias que cuenten con registros y que medianamente hayan respetado una metodología de implementación científicamente analizable. Lo que sí es seguro es que ha tenido un efecto inmensamente positivo en la atención de la salud. Y para ser pragmáticos y precisos en este sentido, puedo mencionar con orgullo que en la Clínica Pasteur se implementó un protocolo de telemonitoreo domiciliario mediante telemedicina gratuito, que fue publicado en sus inicios en Marzo de 2019, y que aun abierto, y siempre gratuito, lleva más de 870 pacientes efectivos bajo el protocolo, y sobre el cual hemos hecho algunas presentaciones de resultados evidentes preliminares, pero que esperamos poder contar con un análisis más completo para Marzo 2021.
Ha sido una experiencia única e irrepetible desde el contexto en el que se implementó, con la incertidumbre y el temor reinando por sobre una población azotada por una afección viral hasta entonces desconocida para los humanos y sin registro de comportamiento epidemiológico. No tengo dudas de los beneficios otorgados por la telemedicina en todas sus modalidades y formatos, por más precarios que hayan resultado en cada rincón del planeta en el que se hayan implementado.
JAPC: ¿Considera que el futuro de la telesalud se forja en una relación digital entre profesionales de la salud y los pacientes?
RVN: La consulta médica presencial no será nunca reemplazada por la telemedicina, ni la telemedicina pretende reemplazar a la consulta médica presencial, y bajo esta realidad, la telemedicina sin duda alguna seguirá siendo una herramienta para la atención medica, y probablemente continúe evolucionando hasta límites aun ni siquiera imaginados. Hoy la telemedicina puede dar respuesta a gran parte de la demanda de atención de un consultorio habitual, si pensamos en recetas, evaluación de resultados de estudios, eficacia de tratamientos, consultas de seguimiento, etc., y esto no solo significa optimización de los tiempos, como ya he mencionado, sino también significa optimización de recursos y de costos; y es en este contexto que la telemedicina se tornara cada vez más protagonista de la resolución de las consultas “banales”, para decirlo de alguna manera, de un consultorio presencial, reservando para los casos estrictamente necesarios la presencia del paciente y de su médico en mismo recinto; y esto también es optimizar los niveles de atención y gestión de salud acorde a las necesidades y requerimientos de cada población en particular.
JAPC: En su opinión y experiencia, ¿La telesalud sea implementado en América Latina a la misma velocidad que en otras regiones durante la crisis sanitaria mundial (Norte América, Europa, Asia)?
RVN: La Telesalud avanza de la mano con las políticas de estado de cada región o país, y sabemos que Latinoamérica tiene tiempos y recursos diferentes a los países de otros continentes, en especial de Europa y Norteamérica, si miramos hacia arriba en escala de vanguardia. Creo que Latinoamérica ha hecho lo que ha podido, como ha podido y con lo que ha tenido a mano; y en este último punto si veo una cualidad a recalcar en una sociedad que siempre encuentra la forma de hacer las cosas, con ingenio de supervivencia forjado por años de necesidades y limitaciones de recursos, digna de mencionar y que además en las sociedades más estructuradas, este poder de inventiva, habitualmente no florece. Es probable que este punto sea, en parte, la clave del éxito de un latinoamericano en el extranjero.
Para contestar resumidamente la pregunta la respuesta es no, no se ha implementado ni a la misma velocidad ni con los mismos recursos que otras partes del mundo, pero ha generado procesos y proyectos con gran originalidad e inventiva que ha dado una solución emergente a las necesidades de la población.
¿Habrá sido suficiente?… no lo sé.
JAPC: En base a lo anterior, ¿Cuáles considera son los retos en América Latina en el avance de la telesalud?
RVN: Es muy importante consensuar un criterio homogéneo de utilización de los recursos tecnológicos en Latinoamérica y construir un espacio de referencia continental para respaldar los proyectos surgentes y avalas las experiencias realizadas, compartir es el paradigma actual para fortalecer los cimientos de la telesalud, no solo a nivel local sino también a nivel mundial.
Es la visión y misión de una red colaborativa como lo propone CRISTAL a través de sus miembros, celebro su creación y apoyo incondicionalmente su crecimiento.
JAPC: ¿Hay algún consejo que le gustaría compartir a aquellos jóvenes médicos o profesionales de la salud que quieren o desean usar las tecnologías para la atención medica?
RVN: La formación en informática en salud y todas sus formas de implementación es tan importante como aprender a utilizar un estetoscopio. Es y será una herramienta de uso habitual para la práctica médica y su correcta utilización será relevante para la salud de sus futuros pacientes, que, en definitiva, seremos nosotros. La Telesalud, es un estetoscopio con una manguera un poco más larga de lo convencional y virtual, que nos permite estar en contacto con nuestro paciente, y resolver la gran mayoría de sus inquietudes sin siquiera pegar la oreja al tórax. A colación, sepan que ya la auscultación cardiaca vía telemedicina ya es una realidad, y el futuro en desarrollo de inteligencia artificial, brillante y de ustedes los jóvenes médicos y profesionales de la salud.
JAPC: En 2020 celebró su primer Congreso Virtual en Telesalud y Telemedicina, donde fungió como Presidente organizador del evento ¿Cuál fue el aporte de este evento en su opinión a las personas que se conectaron de distintos países? ¿En lo personal que le dejo?
RVN: Fue una gran experiencia y agradezco a la AITT la confianza depositada en mi para presidir el congreso. Durante el proceso de gestión del evento surgió un gran espíritu de trabajo y equipo en las personas que me rodearon y que sin ellas no hubiese podido sortear los obstáculos que se nos fueron presentando, no solo externos, sino también internos y de magnitud considerable. Finalmente pudimos ofrecer un primer evento virtual, innovador en su momento, que contó con exponentes de primer nivel mundial, de calidad y expertise de lujo. El congreso impacto significativamente en el auditorio presente y lo más importante de todo es que fue inspirador para vencer miedos y prejuicios en proyectos de telesalud.
Quedamos exhaustos y satisfechos con la conclusión de la tarea titánica que nos propusimos y que sin duda despertamos proyectos dormidos y dejamos al descubierto las nuevas barreras a vencer.
Fue un éxito rotundo. Mi sensación final es de agradecimiento y satisfacción.
JAPC: ¿Qué significa la seguridad del paciente en el contexto de las soluciones digitales o móviles?
RVN: La historia clínica del paciente, así como sus consultas, son documentos absolutamente privados y el resguardo de la información que contienen es fundamental, es por eso que se deben plantear desarrollos de telemedicina con bases en conjuntos de estándares informáticos que garanticen la seguridad del traspaso de datos. Argentina es miembro de HL7 y nosotros hemos edificado las soluciones informáticas sobre esas bases. La continuidad y fluidez de avance de la Telesalud depende directamente de la garantía de seguridad informática y su trazabilidad.
JAPC: La práctica de la telemedicina ha eliminado muchas barreras físicas y emocionales para la búsqueda de atención médica, pero han planteado muchos problemas legales y éticos en la región ¿Considera que hay avances regulatorios?
RVN: Si, hay avances regulatorios, pero siempre vienen detrás de toda implementación o innovación. Primero una idea se vuelve realidad, se ejecuta en prototipos y luego queda a disposición de los usuarios; cuando la cantidad de usuarios se torna importante comienza a enmarcarse y regularse su utilización. Para ejemplificarlo mejor podemos mencionar las motos eléctricas; que ya se está utilizando desde hace tiempo y en primera instancia no era necesario tener licencia ya que para conducir motos se tomaba como parámetro la cilindrada, y las motos eléctricas carecen de cilindros ya que no son a combustión y entonces quedaban fuera de las categorías de vehículos urbanos, tampoco era obligatorio la utilización de cascos y a su vez entorpecían las bici sendas y sus velocidades han ido in crescendo; en Argentina recientemente se ha comenzado a regular las licencias y permisos, así como los seguros de coberturas de daños a terceros. Y con este ejemplo queda claro que muchos de los avances, sobretodo tecnológicos, estarán fuera de los marcos regulatorios vigentes hasta que la utilización masiva obligue a consideran su propia legislación. Con la telesalud pasa lo mismo. El problema surge muchas veces por que la velocidad de avance tecnológico es muy superior a la velocidad de la organización y gestión de procesos regulatorios.
JAPC: ¿Practica usted o ha practicado Telemedicina Internacional?
RVN: No la he practicado y este es un punto que urge regular. Mi licencia de medico permite ejercer la profesión en el territorio nacional que la haya otorgado y para atender pacientes de otros países se debe homologar el título. La atención vía telemedicina no debería ser considerada una excepción a esto. Más allá de los temas de licencia hay cuestiones de praxis y legales que quedan en un limbo de grises con consecuencias difíciles de resolver. Pensemos en circunstancias trágicas de mala praxis para dimensionar el tema y de esa manera tomar conciencia de los potenciales riesgos que eso conlleva y de la impunidad que sin regulación podría prevalecer. Hay tres escenarios que pueden ser una excepción a este concepto, y son los siguientes:
- En primer lugar, el domicilio legal del paciente determina el radio de cobertura de las licencias médicas en el caso de la Telemedicina. Esto quiere decir que, si yo estando en Argentina atiendo a un paciente que tiene domicilio en Argentina, pero se encuentra en el extranjero físicamente por alguna razón la atención medica no estaría violando ninguna legislación ni del país extranjero ni de la nacionalidad del paciente, y por supuesto las consecuencias legales del acto médico están delimitados en la legislación del país habilitante. Lo mismo sucede con los estados o provincias dentro de un mismo país, también hay regulaciones provinciales para la atención medica y tal cual el ejemplo anterior es el domicilio legal del paciente quien determina la habilitación para la atención para un determinado médico.
- El segundo escenario posible es lo que se asemeja más a una interconsulta. Imaginemos que un paciente extranjero se encuentra en otro país, con su médico presencial a su lado y realizan una teleconsulta con otro médico que está en Argentina. En este caso si bien el medico argentino está siendo consultado el medico presencial es quien está asumiendo la responsabilidad del acto médico y su repercusión sobre el paciente.
- Hay un tercer escenario que está rayando los grises en cuanto la consulta en si y se trata de consultas asincrónicas vía email con instituciones extranjeras y que además está muy de moda ahora. Se trata de consultas médicas privadas con envío de información y estudios vía email a instituciones y médicos de prestigio mundial que luego de analizar el caso devuelven la evaluación y sugerencias terapéuticas. Técnicamente continúa siendo una consulta médica a la distancia con un médico no avalado para la atención de salud en el territorio de origen del paciente, sin embargo, el hecho de que sea asincrónica quita la espontaneidad de la consulta y plantea un escenario diferente; a su vez no hay nada que impida el contacto de pacientes con estas instituciones, y además en estos casos la responsabilidad de toma de decisiones también podría ser compartida con médicos locales o por los pacientes mismos. En este punto falta pulir los escenarios extremos para no dejar cabos sueltos en su legislación. Mientras tanto, como sucede con las motos eléctricas, ya son moneda corriente.
JAPC: ¿Considera que la colaboración entre instituciones de salud de distintos países dejando bien claras las reglas de operación es viable y factible?
RVN: Por supuesto, no solamente es viable, sino que es una realidad y por sobretodo una necesidad. Se debe dejar muy en claro las obligaciones, derechos y obligaciones de cada extremo de la teleconsulta y por ende las responsabilidades de las consecuencias.
JAPC: Usted encabeza el Departamento de Telesalud en la Clínica Pasteur en Neuquén Argentina, ¿Nos puede explicar de manera general la modalidad de consultorio virtual?
RVN: El departamento de Telesalud de la Clínica Pasteur Neuquén contiene numeroso proyectos y procesos de incorporación informática a la asistencia médica, dentro de ese conjunto se destaca la Telemedicina y dentro de la modalidad está disponible el consultorio virtual que a su vez tiene diferentes instancias.
- En primer lugar, está el consultorio virtual programado. En esta modalidad los médicos tienen una agenda habitual habilitada, sea semanal, mensual, etc., con días y horarios determinados de atención y los pacientes toman los turnos con al menos 24 hs de anticipación. En los horarios de la agenda del médico el profesional está conectado y disponible para la atención y es el paciente quien, al horario seleccionado, inicia la videoconsulta con su médico; en el caso de estar ocupado el medico el paciente ingresa en una “sala de espera virtual” y en líneas generales los tiempos de espera son muy cortos. Tenemos varios profesionales y diversas especialidades disponibles para la atención tales como clínica medica, dermatología, endocrinología, traumatología, cardiología, rehabilitación, etc.
- En segundo lugar existe la posibilidad de realizar atención a demanda espontanea, con programas de atención y seguimiento de pacientes como por ejemplo en programa de Telemeonitoreo domiciliario para pacientes COVID que involucra además, de la videoconsulta diaria, un kit de medición de signos vitales lo que ha permitido la detección precoz de situaciones potencialmente riesgosas y su inicio de tratamiento o derivación a internación de ser necesario.
- Como tercer instancia está disponible la interconsulta con las especialidades y subespecialidades de la Clínica Pasteur por parte de médicos del interior de la Provincia. Esta particularidad acerca a los profesionales, difícilmente accesibles desde áreas campestres alejadas, con los médicos generales y sus pacientes.
Aún hay mucho por hacer, el departamento está en pleno desarrollo y para esto el sostén y el apoyo debe ser institucional.
JAPC: En el Departamento de Telesalud en la Clínica Pasteur en Neuquén Argentina, sé que debe haber muchos logros y satisfacciones, ¿Cuál ha sido su mayor satisfacción? y ¿Cuál su mayor desafío?
RVN: La satisfacción de nuestros pacientes es nuestra satisfacción. Pero creo que fue en los últimos dos años que quedo en evidencia lo importante que es derribar los muros y la distancia entre médicos y pacientes a través de tecnología aplicada a la salud. Y es así que durante los momentos más críticos de la pandemia de covid-19 los pacientes se refugiaron en la plataforma de telemedicina y encontraron no solamente contención asistencial sino también un acompañamiento humano invaluable. De hecho, tratamos de medir, mediante una encuesta de satisfacción reciente, las opiniones de los usuarios pacientes y nos encontramos con relatos y agradecimientos inimaginables. Estamos ilusionados y entusiasmados con el potencial desarrollo de las prestaciones que ofrece la Telesalud, pero siempre tomamos nuestros logros con gran sentido de pertenencia institucional y humildad, es necesario ser empático con la crítica y compasivo con el paciente, después de todo al finalizar el juego el Peón y el Rey se guardan en la misma caja.
JAPC: ¿Cuáles son algunas recomendaciones concretas que puede ofrecer a otras organizaciones o miembros que deseen desarrollar programas de Telesalud?
RVN: Ya lo he mencionado antes, pero el rol de la dirección medica y administrativa de la entidad que respalde el proyecto es determinante. Para concretar programas de Telesalud se requiere de un agregado institucional que pueda identificar, dentro de su misión y visión, el desarrollo de la disciplina como un pilar de crecimiento. Para esto es fundamental dedicarle recursos exclusivos y un desempeño independiente de otros departamentos; esto significa que los recursos humanos afectados deben tener dedicación exclusiva, al menos dentro de la institución, y se le debe asignar un presupuesto de inversión con un plan de recupero basado en unidades de negocios y cronogramas de avances predeterminados.
La planificación es clave. Dentro del esquema de proyección es conveniente dedicarle aproximadamente el 30% del tiempo estipulado a la planificación de detallada de los procesos. Esto puede generar reticencia y desconfianza para el financiador, pero con estructuras formales de análisis y metas entregables fijadas esta etapa “de escritorio” se construye adecuadamente y eventualmente se consolida y se potencia en la etapa de implementación.
JAPC: Sabemos que en temas de medicina y salud digital hay que estar en un constante aprendizaje, actualmente ¿está realizando estudios?, si su respuesta en afirmativa ¿en qué y porque decidió estudiar eso?
RVN: Claro que sí, siempre he estado en constante formación, estar siempre actualizado es una cruz de oro macizo que el médico debe cargar hasta el final de su ejercicio, y yo nos soy la excepción; desde la formación en la residencia de Terapia Intensiva y los postgrados en diversas subespecialidades el constante avance de la medicina y la ciencia es un motor que ha sido y será parte de mi vida profesional.
La asimilación de información e incorporación a procesos de aprendizaje es la base de la evolución, el desarrollo y la consolidación de los proyectos innovadores. En relación a Telesalud en este momento me encuentro finalizando la primera mitad de la Maestría en Informática en Salud que dicta el Hospital Italiano de Buenos Aires con aval y certificación internacional.
JAPC: ¿Hay algo más que le gustaría decir sobre la influencia de la telesalud/telemedicina en el entorno actual de COVID-19?
RVN: La pandemia de COVID-19 le dio el puntapié final, en la rampa de lanzamiento, a la Telesalud. Debemos depurar los elementos de construcción positiva y potenciar sus cualidades. La tecnología continúa mejorando a una velocidad vertiginosa y nosotros flotamos en la correntada de su avance con apenas noción de lo que se mueve en nuestro entorno. La formación continua, la planificación y los consensos son los cimientos de lo que viene. El futuro está en manos de los que vienen detrás y nosotros debemos dejar la cancha lista y en las mejores condiciones posibles.
JAPC: Agradezco al Dr. Ramiro Vaca Narvaja, por colaborar, por promover la telesalud y por su tiempo en este ejercicio informativo, nuestra comunidad lectora estará muy satisfecha por su aporte.
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In my opinion, it could make your posts a little livelier.
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