ABC | Volume 113, Nº4, October 2019

Editorial Behavioral Economics and Innovation Uptake: Building New Capabilities to Overcome Barriers to Technology-Enabled Care Alexandre Siciliano Colafranceschi 1,2,3 Universidade Federal do Estado do Rio de Janeiro, 1 Rio de Janeiro, RJ – Brazil Instituto Nacional de Cardiologia, 2 Rio de Janeiro, RJ – Brazil Hospital Pró-Cardíaco, 3 Rio de Janeiro, RJ – Brazil Mailing Address: Alexandre Siciliano Colafranceschi • Instituto Nacional de Cardiologia - Cirurgia Cardíaca - Rua das Larangeiras, 374. Postal Code 22240-002, Rio de Janeiro, RJ – Brazil E-mail: alexandre.siciliano@gmail.com Keywords Telemedicine/economics; Telemedicine/legislation and jurisprudence; Telemedicine/trends; National Health Science, Technology and Innovation Policy; Telemedicine/methods DOI: 10.5935/abc.20190216 Introduction The Federal Medical Council (CFM) has recently published a new resolution on telemedicine in Brazil. The 2227/2018 resolution, establishing the criteria for the use of telemedicine, was published in Diario Oficial da União (DOU, the official journal of the federal government of Brazil) on February 6, 2019. 1 This new policy, aimed at defining telemedicine as a way of providing medical services by means of technology, is much more aggressive than the previous one published in 2002, which limited the use of telemedicine to medical consultations made by telephone or internet, and implied the presence of a health professional at both ends of the communication channel. The current resolution expanded the concept of telemedicine in providing technological solutions for remote patient monitoring and treatment (drug prescription and surgical interventions), and analysis of laboratory results. However, soon after its release, the new document caused an intense public debate on the theme dividing stakeholders for and against the incorporation of telemedicine into practice nationwide. The debate was so intense that the Federal Medical Council revoked the resolution, as published in the DOU on March 6, 2019. 2 The revocation of the policy after intense societal debate indicates the significant challenges regarding the implementation of technology-enabled care in Brazil. Such debate should not be the end, but rather, the beginning of a social mobilization to reframe the use of connected technology in healthcare in the country. To tackle the barriers to the uptake of technology‑enabled care in Brazil, one should better understand the stakeholder positions, and consider the political and cultural environment, the ethical and legal apparatus and the available technology infrastructure. 3 A more comprehensive understanding of the contemporary scenario where technology-enabled care may fit into Brazilians’ needs is critical to suggest approaches that might lead to societal benefit while being acceptable by physicians and other stakeholders. Objectives This is an exploratory paper, aiming to provide a personal overview of potential barriers to the incorporation and dissemination of telemedicine in Brazil. It is also an objective to discuss potential approaches to overcome these barriers. A) Analysis of the stakeholders A.1) The State and Telemedicine - The Government as a stakeholder From the political point of view, government initiatives concerning telemedicine have been led primarily by the Brazilian Ministry of Health and were designed to promote the use of telemedicine in the expansion and improvement of health services. The dimensions involved, however, are beyond the limits established by the Ministry of Health. An effective inter-ministerial action would be required to foster the economy (innovation and economic efficiency) and the social dimension (interest of the population and equality) to leverage telemedicine towards the expansion and improvement of healthcare. A.2) Challenging the “status quo” - Providers as stakeholders: institutions, physicians and other practitioners Culture is another limiting factor in the dissemination of telemedicine from the perspective of institutions, physicians and other practitioners. From the need for adjusting to the new working process, to the challenging relationship between power structure and professional structure, the adoption of the latest technology may generate significant resistance. The resistance to change is strengthened by the risk aversion 4 and uncertainties that are commonly related to the introduction of a "new way of doing things". On the one hand, technology-enabled care may help overcome the obstacle of access posed by the distance (especially in a continental-dimension country like Brazil) with expected gains with the information and communication technologies, i.e ., by increasing access and reducing costs. However, the interdependence between telemedicine and health services organization in guiding new investments may cause a shift in the arena of power. These complexities and uncertainties pose a substantial barrier to the dissemination of the new technologies. Likewise, telemedicine faces resistances from practitioners. 2 Telemedicine involves multidisciplinary players, encompassing health practitioners of diverse disciplines, information and communication technology experts, managers and policy makers. The adoption of this technology requires the redesigning of work processes in their multiple aspects that generate tensions and conflicts. 664