Consensus Document
Executive summary on the use of telemedicine in the hospital setting: Recommendations from the International Forum on Internal Medicine
Resumen ejecutivo sobre el uso de la telemedicina en el ámbito hospitalario: recomendaciones del Foro Internacional de Medicina Interna
E. Casariego-Valesa,
, R. Palencia-Vizcarrab, J. Bolañoc, L. Cámerad, P. Valdeze, on behalf of the TELE-FIMI Working Group 1
Corresponding author
a Sociedad Española de Medicina Interna, Hospital Universitario Lucus Augusti, Lugo, Spain
b Colegio de Medicina Interna de México, Guadalajara, Jalisco, Mexico
c Sociedad Argentina de Medicina, Universidad Nacional del Nordeste, Hospital Perrando, Resistencia Chaco, Argentina
d Sociedad Argentina de Medicina, Universidad de Buenos Aires, Hospital Italiano de Buenos Aires, Caba, Argentina
e Sociedad Argentina de Medicina, Universidad de Buenos Aires, Universidad Nacional de La Matanza, Hospital Vélez Sarsfield, Caba, Argentina
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With the evolution of communications technology in the second half of the 20th century, it began its true development in areas such as teleradiology or telepsychiatry<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>, facilitating medical attention in very remote areas.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In this century—the age of immediacy—the expansion of the internet, new smart phones, innovation in communications infrastructures, and organizational improvements in healthcare programs allow for telemedicine to be used in multiple clinical fields<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The COVID-19 pandemic has accelerated its implementation in various hospital and outpatient sectors. This includes, for example, the at-home monitoring of patients with COVID-19 that is initially not severe or those with chronic diseases<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a>. Although it has been necessary to create new structures, train healthcare personnel, and overcome barriers among users, its use has increased exponentially and it is now perceived as a safe and useful tool<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,8</span></a>.</p><p id="par0020" class="elsevierStylePara elsevierViewall">It is evident that telemedicine offers new opportunities, many of which remain to be discovered. But, as in all rapidly expanding areas, the initial experiences are mixed. On the one hand, there is a plethora of evidence in its favor given that, for various diseases and situations, it has been demonstrated to be efficient and relatively easy to integrate into healthcare organization<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9–12</span></a>. However, failures have also been reported and both healthcare personnel and patients have found limitations and barriers to its use<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13–15</span></a>. For these reasons, knowledge gaps, organizational deficiencies, and legal questions which hinder its dissemination in daily clinical practice undoubtedly still exist.</p><p id="par0025" class="elsevierStylePara elsevierViewall">This document summarizes the position of the International Internal Medicine Forum (FIMI, for its initials in Spanish) on the clinical use of telemedicine in patient care in the hospital setting. Its aim is to establish aspects to improve and offer recommendations so that its use is efficient and safe.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">Given the need to delve deeper into the challenge that the implementation of telemedicine in the hospital setting entails, in March 2021, the FIMI leadership formed a working group comprising five physicians from scientific societies from three countries that form part of the forum. The individuals selected had previous experience in the development and/or implementation of telemedicine in various hospital settings in their respective countries.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The overall aim was to propose a general framework that allows for the development and implementation of hospital clinical care with telemedicine that would be useful to the various FIMI member countries. The secondary aims included:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a</span><p id="par0040" class="elsevierStylePara elsevierViewall">Agree on proposed terminology regarding the definition and scope of new terms used when working with this tool.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b</span><p id="par0045" class="elsevierStylePara elsevierViewall">Revise and update the catalog of telemedicine services in the hospital setting.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c</span><p id="par0050" class="elsevierStylePara elsevierViewall">Know the existing barriers to implementation and establish actions that internal medicine societies can take to overcome them in their various countries.</p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall">This work begins with a narrative review on telemedicine’s development and a proposal of FIMI recommendations has been made. The working group conducted a search for documents about telemedicine in the hospital setting in the TRIP database by means of a non-systematic exploratory method. This search was complemented with the tracing of references included in the documents obtained and with contact with experts in the field.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The search period ended in August 2021. The document was drafted in weekly meetings held <span class="elsevierStyleItalic">via</span> video conference between March and September 2021. Later, a two-round Delphi method was used as a consensus creation strategy. Fifty-one experts from 20 countries participated in them. Of them, 48 were in representation of 20 internal medicine societies from 17 countries (Appendix B).</p><p id="par0065" class="elsevierStylePara elsevierViewall">The complete final document is available on the FIMI website: <a href="https://webfimi.meducar.com/noticia/recomendaciones-del-foro-internacional-de-medicina-interna-fimi-acerca-del-uso-de-la-telemedicina-en-el-mbito-hospitalario/2374">https://webfimi.meducar.com/noticia/recomendaciones-del-foro-internacional-de-medicina-interna-fimi-acerca-del-uso-de-la-telemedicina-en-el-mbito-hospitalario/2374</a>.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">The executive summary of FIMI recommendations can be found below.</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">General aspects</span><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 1.</span> All hospital centers (or chains) should have their own separate telemedicine department which can be adapted to the needs of different users.</p><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 2.</span> Alternatively, it is possible to group several centers together to share resources and services, provided that they offer the same services.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Technical aspects</span><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 3.</span> The telemedicine department should be fully integrated into the electronic medical record in places where it is available.</p><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 4.</span> Its structure must allow for secure, high-quality connections.</p><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 5.</span> Its organization must support secure, effective data storage.</p><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 6.</span> Its procedures must be flexible to allow for the progressive connection of multiple devices of very diverse natures which will surely emerge in upcoming years.</p><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 7.</span> The system must be able to be expanded to new departments and functions without this changing the interface or the manner of working or connecting.</p><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 8.</span> Regardless of whether the various departments connect from their own facilities or offices, it is advisable to have a central virtual ward.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Hospital personnel in charge</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 9.</span> All professionals considered necessary for the aims to be achieved will form part of the department.</p><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 10.</span> All personnel who work full-time or part-time in this area must have the training necessary to properly perform their roles. Likewise, it is advisable to establish a learning curve according to the profession in detail. Scientific societies must define and structure this training.</p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 11.</span> Given that this service may be available 24<span class="elsevierStyleHsp" style=""></span>h a day, organizing shifts will be necessary. A conventional hospitalization ward can be used as a model.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Patients</span><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 12.</span> The selection of patients who may be users of this service will be done based on the disease care programs available at the center.</p><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 13.</span> Both patients and their families should receive basic information on the system’s operation.</p><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 14.</span> Patients should be free to accept or reject this medical monitoring system after a detailed explanation of the benefits intended to be achieved and the rules for its use.</p><p id="par0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 15.</span> The patient must be free to leave this monitoring system when he or she wishes.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Basic rules for use</span><p id="par0150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 16.</span> All aspects of the activity must be subject to previously established rules and work protocols which are periodically revised and updated.</p><p id="par0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 17.</span> At-home connection must be done in a simple manner and, when possible, using the patient’s own devices.</p><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 18.</span> Telemedicine monitoring must be started only after establishing the aims intended to be achieved.</p><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 19.</span> Telemedicine monitoring must be as brief as possible, though it is possible that successive periods of use may be needed.</p><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 20.</span> If the patient does not have data collection devices (or if they are not compatible), the hospital should provide them during the monitoring period and they should later be returned to the center for their sterilization.</p><p id="par0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 21.</span> The response mechanisms when faced with an emergency or clinical decompensation must be well-established, easy for the patient to access, and provide a rapid response.</p><p id="par0180" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 22.</span> The response protocols when faced with a medical emergency must consider all possibilities and must be known by the entire organization.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Ethical and legal aspects</span><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 23.</span> The hospital must have suitable informed consent templates for the use of this service.</p><p id="par0190" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation 24.</span> Every effort must be made to adapt each country’s current legal provisions to the technological evolution of these tools for medical use.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Discussion</span><p id="par0195" class="elsevierStylePara elsevierViewall">This document describes the FIMI’s position on the use of telemedicine in the hospital setting and is applicable to all centers in the countries which form part of this society. The final text has been unanimously accepted by all members of the working group. Our understanding is that it allows for laying a foundation for the creation of new teams and for the concordant development of already established teams.</p><p id="par0200" class="elsevierStylePara elsevierViewall">This initiative arose out of a need to harmonize both the creation and the development of this department, given the disparities among hospital centers (of different sizes and with different equipment) of different countries (with distinct cultures and laws) detected by the FIMI. The final aim was to have a broad, robust agreement that allows for providing the public with a suitable service of proven quality. Therefore, this document is not a rigid guide for use, but rather a set of basic instructions whose application is flexible that guide both the creation of new departments and the adaptation of existing ones.</p><p id="par0205" class="elsevierStylePara elsevierViewall">The benefits of following these recommendations are evident on multiple levels. In regard to care, they allow for having a work framework of proven quality in areas where telemedicine has already demonstrated its value. In regard to legal matters, they provide support for an activity that is governed by very distinct or even nonexistent regulations in different countries. In regard to administration, they allow for having a foundation for its development according to needs. Lastly, in regard to clinical research, they allow for developing projects with a common foundation.</p><p id="par0210" class="elsevierStylePara elsevierViewall">This initiative also intends to achieve other aims that are no less important. First, it aims to offer an agreement on terminology regarding various concepts associated with the use of this tool. New expressions, which are specific to activities which are in development, can be confusing. Therefore, an effort has been made in this document to propose precise definitions for the most common terms (link to the FIMI website: <a href="http://webfimi.meducar.com">http://webfimi.meducar.com</a>). Second, it has classified the clinical areas in which telemedicine has been demonstrated to impact healthcare. Our understanding is that this may serve users when it comes to establishing areas for development in their centers. Lastly, the proposal suggests activities, protocols, and work methods that allow for eliminating or limiting the impact of the most frequently detected barriers to implementation.</p><p id="par0215" class="elsevierStylePara elsevierViewall">When evaluating this document, certain limitations must be taken into account. First, the available evidence increases exponentially in very short periods of time. Therefore, its period of validity is limited. The authors believe that a comprehensive revision of this document will be necessary in a maximum period of 2 years. Second, the study focuses on the hospital setting in certain countries. Therefore, we understand that its conclusions may not be valid in other settings. Lastly, the legal basis for this medical activity may be confusing or nonexistent in certain countries. Therefore, we suggest that the various scientific societies in the countries that reached this consensus evaluate the situation in their nation and begin the necessary processes for adapting local regulatory aspects to this new reality. The aim is to offer healthcare of the greatest possible quality with the security of complying with the current legal framework.</p><p id="par0220" class="elsevierStylePara elsevierViewall">In conclusion, this document presents the FIMI’s recommendations on the use of telemedicine in the hospital setting with the aspiration of guaranteeing effective, safe, efficient, sustainable, and proportional healthcare interventions based on the best scientific evidence available.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicts of interest</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Funding</span><p id="par0230" class="elsevierStylePara elsevierViewall">The authors, the participating scientific societies, and FIMI confirm that there has been no type of funding, participation, or collaboration from institutions or companies in the private sector in the creation of this document.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres1831143" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1596337" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1831144" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1596336" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "General aspects" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Technical aspects" ] ] ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Hospital personnel in charge" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Patients" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Basic rules for use" ] 10 => array:2 [ "identificador" => "sec0045" "titulo" => "Ethical and legal aspects" ] 11 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 12 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of interest" ] 13 => array:2 [ "identificador" => "sec0060" "titulo" => "Funding" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-12-19" "fechaAceptado" => "2021-12-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1596337" "palabras" => array:4 [ 0 => "Telemedicine" 1 => "Hospital" 2 => "Case management" 3 => "International Consensus" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1596336" "palabras" => array:4 [ 0 => "Telemedicina" 1 => "Hospital" 2 => "Gestión de casos" 3 => "Consenso internacional" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The implementation of telemedicine as another tool for patient care in the hospital setting is a challenge for any healthcare system. Given the difficulties and limitations, the International Forum on Internal Medicine (FIMI, for its initials in Spanish) has sponsored this consensus document with 20 scientific societies from 17 countries in Europe and the Americas. The aim was to propose a general framework that allows for the development and implementation of telemedicine in hospital clinical care that would be useful to FIMI member countries. The document we present includes recommendations from the FIMI in its executive summary that intend to guarantee effective, safe, efficient, sustainable, and proportional healthcare interventions based on the best scientific evidence available. The authors believe that this document must be updated within a maximum period of two years.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La implantación de la telemedicina como una herramienta más en la atención a pacientes en el ámbito hospitalario es un reto para cualquier sistema sanitario. Dadas las dificultades y limitaciones, el Foro Internacional de Medicina Interna (FIMI) ha promovido este Consenso que incluye a 20 sociedades científicas de 17 países de Europa y América. El objetivo fue realizar una propuesta, a modo de marco general, que permitiese el desarrollo e implantación de la telemedicina en la atención clínica hospitalaria y que fuese útil para los diferentes países integrantes del FIMI. El documento que presentamos recoge el resumen ejecutivo de las recomendaciones de la FIMI que pretenden garantizar intervenciones sanitarias efectivas, seguras, eficientes, sostenibles y proporcionadas y basadas en la mejor evidencia científica disponible. Los autores consideran que este documento debe actualizarse en el plazo máximo de dos años.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">More information on the TELE-FIMI Working Group can be consulted in Appendix A of this article.</p>" "identificador" => "fn0005" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:2 [ 0 => array:4 [ "apendice" => "<p id="par0235" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Argentina</span>: Rodrigo Sabio (Fundación Patagónica de Prevención Cardiovascular. El Calafate).</p> <p id="par0240" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Bolivia:</span> Coral Cristaldo Id (Centro Médico Foianini. Santa Cruz de la Sierra), Silvana Gonzales Cárdenas (Hospital San Juan de Dios, Tarija), Ana Sapag Durán (Hospital Universitario Japonés, Santa Cruz de la Sierra), Rene Tejerina (Hospital Obrero N.°7 de la Caja Nacional de Salud, Tarija).</p> <p id="par0245" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Chile</span>: Luis Rojas Orellana (Hospital Clínico UC Christus, Santiago).</p> <p id="par0250" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Colombia</span>: Yazmín Abuabara Turbay (Hospital Universitario del Caribe, Cartagena), Tatiana Espinoza Espitia (Hospital San Diego, Montería), Homero Puello Galarcio (Huila Neiva, Huila).</p> <p id="par0255" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Costa Rica</span>: Carlos Araya Fonseca (Hospital Dr. Rafael Ángel Calderón Guardia, San José).</p> <p id="par0260" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cuba</span>: Isis Betancourt (Universidad de Ciencias Médicas de La Habana, La Habana), Miguel Blanco Aspiazu (Policlínico Ramón González Coro, La Habana), Emilio Buchaca Faxas (Hospital Hermanos Ameixeiras, La Habana), Miguel Ángel Serra Valdés (Hospital General Docente Enrique Cabrera, La Habana).</p> <p id="par0265" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Ecuador</span>: Santiago Carrasco Dueñas (Hospital Club de Leones Quito Central, Quito).</p> <p id="par0270" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">El Salvador</span>: Karen Cárcamo de Villatoro (Hospital El Salvador, San Salvador), Rubén Montufar Guardado (Profesor Asociado del ISSS, San Salvador).</p> <p id="par0275" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Spain</span>: Jesús Díez-Manglano (Hospital Royo Villanova. Zaragoza).</p> <p id="par0280" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Guatemala</span>: Sergio Castañeda Cerezo (Hospital Pedro de Bethancourt, Antigua Guatemala).</p> <p id="par0285" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Honduras</span>: Helga Codina (Hospital Medical Center, Tegucigalpa), Lorenzo Díaz Salazar (Hospital Universitario Hospital Militar Central, Tegucigalpa).</p> <p id="par0290" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Mexico:</span> Alfredo Cabrera Rayo (Hospital Regional 1.° de Octubre, Ciudad de México), Nikos Christo Secchi Nicolas (Instituto Mexicano de la Seguridad Social. Coatzacoalcos, Veracruz), Rodolfo Palencia Díaz (Hospital de Especialidades Centro Médico de Occidente. Guadalajara).</p> <p id="par0295" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Nicaragua</span>: Bismarck Pérez (Servicio Sanidad Militar. Managua).</p> <p id="par0300" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Panama</span>: Juan Barrios (Hospital Santo Tomás, Ciudad de Panamá).</p> <p id="par0305" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Paraguay</span>: Gustavo Arbo Oze de Morvil (Unidad del Centro de memoria de Investigación. Asunción), Hugo Celauro Falcón (Sociedad Paraguaya de Medicina Interna, Asunción), Jesús Falcón Zorrilla (Sociedad Paraguaya de Medicina Interna, Asunción).</p> <p id="par0310" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Peru</span>: Aland Bisso Andrade (Clínica Delgado. Lima), Diana Rodríguez Hurtado (Hospital Nacional Arzobispo Loayza, Lima), Sonia Indacochea Cáceda (Hospital Nacional Edgardo Rebagliati Martins, Lima), Eduardo Penny Montenegro (Clínica Delgado. Lima).</p> <p id="par0315" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Portugal</span>: Luis Campos (Hospital S Francisco Xavier. Lisboa), Lèlita Santos (Centro Hospitalar e Universitario. Coimbra).</p> <p id="par0320" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Dominican Republic</span>: Claudia Arias (Centro Médico Universidad Central del Este, Santo Domingo), Emilio Arias Arias (Clínica Unión Médica del Norte. Santiago de los Caballeros), Sergio Díaz Silverio (Hospital Metropolitano. Santiago de los Caballeros), José Galarza Núñez (Hospital Regional Universitario José María Cabral y Báez, Santiago de los Caballeros), Altagracia Mejía Terrero (Centro Médico Antillano, Santo Domingo).</p> <p id="par0325" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Uruguay</span>: Gustavo Bruno (Hospital Maciel, Montevideo), Ana Laura Taborda (Hospital Maciel, Montevideo), Andrea Vaucher Rivero (Hospital Maciel, Montevideo).</p> <p id="par0330" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Venezuela</span>: Maritza Durán (Hospital Universitario de Caracas, Caracas), Mario Patiño (Facultad de Medicina. Hospital Universitario de Caracas, Caracas), Virginia Salazar Matos (Hospital Militar Dr. Carlos Arvelo, Caracas).</p>" "etiqueta" => "Appendix A" "titulo" => "TELE-FIMI Working Group" "identificador" => "sec0065" ] 1 => array:4 [ "apendice" => "<p id="par0335" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Argentina:</span> Sociedad Argentina de Medicina.</p> <p id="par0340" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Bolivia:</span> Sociedad Cruceña de Medicina Interna, Sociedad de Medicina Interna de Tarija y Sociedad Boliviana de Medicina Interna.</p> <p id="par0345" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Colombia:</span> Asociación Colombiana de Medicina Interna.</p> <p id="par0350" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cuba:</span> Sociedad Cubana de Medicina Interna.</p> <p id="par0355" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Ecuador:</span> Asociación Ecuatoriana de Medicina Interna.</p> <p id="par0360" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">El Salvador:</span> Asociación de Medicina Interna de El Salvador.</p> <p id="par0365" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Spain:</span> Sociedad Española de Medicina Interna.</p> <p id="par0370" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Guatemala:</span> Asociación de Medicina Interna de Guatemala.</p> <p id="par0375" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Honduras:</span> Sociedad Hondureña de Medicina Interna.</p> <p id="par0380" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Mexico:</span> Colegio de Medicina Interna de México.</p> <p id="par0385" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Nicaragua:</span> Sociedad Nicaragüense de Medicina Interna.</p> <p id="par0390" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Paraguay:</span> Sociedad Paraguaya de Medicina Interna.</p> <p id="par0395" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Peru:</span> Sociedad Peruana de Medicina Interna.</p> <p id="par0400" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Portugal:</span> Sociedad Portuguesa de Medicina Interna.</p> <p id="par0405" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Dominican Republic:</span> Asociación Dominicana de Médicos Internistas y Sociedad de Medicina Interna de República Dominicana.</p> <p id="par0410" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Uruguay:</span> Sociedad de Medicina Interna de Uruguay.</p> <p id="par0415" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Venezuela:</span> Sociedad Venezolana de Medicina Interna.</p>" "etiqueta" => "Appendix B" "titulo" => "Participating Internal Medicine Departments" "identificador" => "sec0070" ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "What is eHealth?: A systematic review of published definitions" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "H. 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| 2023 June | 9 | 0 | 9 |
| 2023 March | 8 | 4 | 12 |
| 2022 June | 6 | 0 | 6 |
| 2022 May | 1 | 2 | 3 |
