Fourteen years after the reform to Colombia’s health system, the promises of universality, improved equity, efficiency, and better quality of care have not materialized. Remote areas remain underserved and access to care very limited. Recognizing teleconsultation as an effective way to improve access to health care and health information, a noncommercial open-access Web-based application for teleconsultation called Doctor Chat was developed.
The objective was to report the experience of the Center for Virtual Education and Simulation eHealth (Centro de Educación Virtual y Simulación e-Salud) with open-access Web-based asynchronous teleconsultation for consumers in Colombia.
A teleconsultation service in Spanish was developed and implemented in 2006. Teleconsultation requests were classified on three axes: (1) the purpose of the query, (2) the specialty, and (3) the geographic area of the query. Content analysis was performed on the free-text queries submitted to Doctor Chat, and descriptive statistics were gathered for each of the data categories (name, email, city, country, age, and gender).
From September 2006 to March 2007, there were 270 asynchronous teleconsultations documented from 102 (37.8%) men and 168 (62.2%) women. On average, 1.4 requests were received per day. By age group, the largest number of requests (n = 80; 30%) were from users 24-29 years, followed by users (n = 66; 24%) 18-23 years. Requests were mainly from Colombia (n = 204; 75.6%) but also from Spain (n = 17; 6.3%), Mexico (n = 11; 4.1%), and other countries. In Colombia, 137 requests (67.2%) originated in Bogotá, the nation’s capital, 25 (12.4%) from other main cities of the country, 40 (19.7%) from intermediate cities, and 2 (0.7%) from remote areas. The purpose of the majority of requests was for information about symptoms, health-related problems, or diseases (n = 149; 55.2%) and medications/treatments (n = 70; 25.9%). By specialty, information was most requested for gynecology and obstetrics (n = 71; 26%), dermatology (n = 28; 10%), urology (n = 22; 8%), and gastroenterology (n = 18; 7%), with anesthesiology, critical care, physical medicine and rehabilitation, and pathology being the least requested (n = 0; 0%). Overall, sexual and reproductive health (n = 93; 34%) issues constituted the main query subject. The average time to deliver a response was 120 hours in 2006 and 59 hours in 2007. Only 19 out of 270 users (7%) completed a survey with comments and perceptions about the system, of which 18 out of 19 (95%) corresponded to positive perceptions and 1 out of 19 (5%) expressed dissatisfaction with the service.
The implementation of a Web-based teleconsulting service in Colombia appeared to be an innovative way to improve access to health care and information in the community and encouraged open and explicit discussion. Extending the service to underserved areas could improve access to health services and health information and could potentially improve economic indicators such as waiting times for consultations and the rate of pregnancy among teenagers; however, cultural, infrastructural, and Internet connectivity barriers are to be solved before successful implementation can derive population-wide positive impacts.
Colombia’s health system, called General Social Security System for Health (Sistema General de Seguridad Social en Salud, SGSSS) is a mixed system (partially publicly funded and partially privately subsidized). Although major improvements have been achieved since the reform in 1993, the promises of universality, improved equity, efficiency, and better quality of care have not materialized [
In spite of the ascending trend over the past years in SGSSS’s overall population coverage (from 36% in 2000 to 74.1% in 2005) [
Almost a decade after the beginning of the new millennium, great attention has been drawn to the application of the emerging information and communication technologies in the health care setting, and health informatics has received recognition as a fundamental strategic component for achieving the greatly desired Global Health Development as stipulated by the “Health for All in the 21st Century” strategy of the World Health Organization (WHO) [
In Colombia, the Internet promises to play a crucial role in health care delivery as usage continues to grow. Penetration has steeply risen from 4.6% in 2002 [
In this context, and with the aim of providing a tool that could serve as a basis for improving access to health care services in the Colombian community by exploring the potential that new technologies can offer to populations in-need, such as those of developing countries, a noncommercial Web-based application for teleconsultation called Doctor Chat [
Internet penetration in Colombia [
Doctor Chat was designed and developed as an open-access free teleconsultation service in Spanish, using a user-centered approach by which needs assessment, interface configuration, and prototyping were conducted by the teleconsultation service’s multidisciplinary team of two physicians, one graphic designer, and one programmer (who also acts as the Web administrator), taking as the baseline referent applications developed elsewhere [
Doctor Chat is composed of a Web-based application structured as a series of HTML pages created by a Web server (Red Hat Enterprise Linux 4) to store and retrieve data in a relational database (MySQL version 5.0.24-standard). The application can be accessed by the general public over the Internet using any Web browser, and it incorporates a synchronous and an asynchronous teleconsultation tool.
Users of Doctor Chat enter the Center’s Web page [
Regardless of the preferred mode of response selected by the user, and in addition to the automatic publication of the question in the asynchronous forum (when requested by the user), each question is automatically directed to a centralized Doctor Chat email account (to which the two physicians and the Web administrator have access) and to the institutional personal email accounts of the two physicians. Only Doctor Chat’s medical team, composed of a senior doctor (a specialist in internal medicine) and a junior doctor (general practitioner), has access to the questions posed. Additionally, a relational database is automatically fed after submission of each question. Along with the response, a single-question informal survey of user’s satisfaction is sent (“Are you satisfied with Doctor Chat’s service? Please send us your comments to improve the service”).
Doctor Chat: how does it work?
Content analysis was performed on the free-text queries submitted to Doctor Chat. Requests were classified according to three schemes: (1) the purpose of the query, (2) the specialty, and (3) the geographic area of the query. A taxonomy of patient requests proposed by Kravitz et al [
Descriptive statistics were gathered for each of the data categories (name, email, city, country, age, and gender) and the location from which each query was submitted was determined by the response to the “country” cell.
Doctor Chat went live on September 15, 2006. From that date to March 22, 2007, 270 teleconsultations from 102 (37.8%) men and 168 (62.2%) women of all age ranges were received (
On average, each of the responses sent by Doctor Chat’s medical team contained 215.4 words (range: 39-832 words). The average time for each response was 120 hours (5 days) during 2006 and 59.04 hours (2.46 days) in 2007.
As selected by all the users, all responses were sent to the email addresses provided in the request.
Among the 270 users of Doctor Chat, 19 (7%) voluntarily replied with their comments and perceptions; 18 of these (95%) were positive perceptions, whereas 1 (5%) expressed dissatisfaction with the service.
Gender and ages of Doctor Chat users
Number | Percentage | |
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Female | 168 | 62.2 |
Male | 102 | 37.8 |
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< 18 | 13 | 4.8 |
18-23 | 66 | 24.4 |
24-29 | 80 | 29.6 |
30-35 | 34 | 12.6 |
36-40 | 24 | 8.9 |
41-45 | 14 | 5.2 |
46-50 | 15 | 5.6 |
> 50 | 15 | 5.6 |
N/A* | 9 | 3.3 |
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*N/A, no answer.
The average number of words per consultation was 48.81 (range: 4-306). On average, each of these consultations contained only one request. By taxonomical category (as described by Kravitz et al [
Among requests for information, 70 (25.9%) consultations belonged to the medications/treatments subcategory; 58 (82.9%) inquired for information about any type of treatment; 7 (2.6%) requested information for prevention of disease, mainly acute myocardial infarction and cancer; 5 (7.1%) asked for information regarding a surgical procedure that the user was to undergo. Another 5 (7.1%) requested information on nonconventional treatments (alternative medicine), and 2 (2.9%) asked for information regarding postsurgical recommendations.
Among the 12 (4.4%) requests that were classified within “other request for information,” 8 (66.7%) searched for data to complete homework or academic assignments and the remaining 4 (33.3%) inquired on how to become an organ donor.
Among requests for action (see
Requests by taxonomical category
Number (%) | ||
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Symptoms, problems, or diseases | 149 (55.2) | |
Psychosocial problems | 0 (0) | |
The physical examination | 0 (0) | |
Test or diagnostic investigations | 7 (2.6) | |
Medications/treatments | 70 (25.9) | |
Prevention | 7 (2.6) | |
Index physician-patient relationship | 0 (0) | |
Other physicians | 1 (0.4) | |
3rd party payer or managed care issues | 0 (0) | |
Other administrative issues | 5 (1.9) | |
Other request for information | 12 (4.4) | |
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Physical examination | 0 | |
Laboratory test, x-rays, or other study | 0 | |
Referral to other physician | 2 (0.7) | |
Referral to nonphysician | 0 | |
Medication/treatments | 17 (6.3) | |
Administrative action: 3rd party payer | 0 | |
Administrative action: other | 0 | |
Other request for action | 0 |
By specialty, requests fell mainly into three areas, in descending order of frequency (
1. Sexual and reproductive health (91 requests, 34%)
All 71 questions (78% of the sexual and reproductive health questions; 26% of total requests) that related to gynecology and obstetrics concerned sexual and reproductive health. Among these, 26 (36%) corresponded to contraception methods, 9 (13%) concerned fetal abnormalities during pregnancy, and 36 (51%) made reference to sexually transmitted infections (STIs).
Among the 22 questions (8% of total requests) related to urology, only 20 (91%) concerned sexual and reproductive health; specifically, these 20 requests inquired about STIs, whereas the other 2 (9%) inquired about prostate cancer and unstable bladder.
Among the 56 (62%) requests related specifically to STIs, 8 (14%; 3% of total requests) asked about HIV/AIDS.
Of the overall 91 (34%) requests regarding reproductive health, 32 (35%) were formulated by users in the 18-23 year age group, 30 (33%) in the 24-29 age group, 15 (16%) in the 30-40 group, 8 (9%) in the over 40 group, and 6 (7%) by users younger than 18 years.
2. Dermatology
There were a total of 28 requests (10%) of which 20 (71%) asked for information regarding removal of striae, moles, scars, or tattoos; 3 (11%) inquired about treatment of acne; 5 (18%) asked about suspected malignant lesions and skin cancer.
Of the 28 dermatology requests, 17 (61%) came from females, and 11 (39%) came from males.
3. Gastroenterology
The 18 (7%) requests for information on gastroenterology specifically concerned irritable bowel syndrome, gastroesophagic reflux, gastritis, acute gastroenteritis, and peptic ulcer.
Users who formulated gastroenterology requests were from both genders and were dispersed among all age groups.
Requests by specialty
Specialty | Number | Percentage |
General medicine | 14 | 5.2 |
Surgery | 4 | 1.5 |
Transplants and organ donation | 8 | 3.0 |
Orthopedics | 8 | 3.0 |
Otorhinolaryngology | 2 | 0.7 |
Plastic Surgery | 2 | 0.7 |
Urology | 22 | 8.1 |
Gynecology and obstetrics | 71 | 26.3 |
Ophthalmology | 3 | 1.1 |
Anesthesiology | 0 | 0.0 |
Internal medicine (general) | 7 | 2.6 |
Cardiology | 11 | 4.1 |
Endocrinology | 6 | 2.2 |
Gastroenterology | 18 | 6.7 |
Nephrology | 1 | 0.4 |
Neumology | 1 | 0.4 |
Dermatology | 28 | 10.4 |
Hematology | 1 | 0.4 |
Neurology | 7 | 2.6 |
Rheumatology | 1 | 0.4 |
Non-traditional medicine | 2 | 0.7 |
Oncology | 3 | 1.1 |
Toxicology and psychoactive substances | 2 | 0.7 |
Critical care | 0 | 0.0 |
Pediatrics | 13 | 4.8 |
Physical medicine and rehabilitation | 0 | 0.0 |
Psychiatry | 7 | 2.6 |
Diagnostic imaging | 1 | 0.4 |
Nutrition | 6 | 2.2 |
Oral health | 5 | 1.9 |
Pathology | 0 | 0.0 |
Others | 16 | 5.9 |
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Among the overall 270 consultations, 7 (2.6%) described emergency-related symptoms: 5 (1.9%) concerned chest pain and 2 (0.7%) denoted pediatric emergencies. Response to these requests was prioritized, and patients were advised to attend an emergency department immediately upon reading the response. These types of requests were given a response in less than 24 hours.
None of the users chose to have their requests published in the asynchronous discussion forum.
Three quarters of consultations were initiated in Colombia, but Doctor Chat received inquiries from several other countries, including Aruba, Spain, and the United States (
Requests by country
Country | Number | Percentage |
Colombia | 204 | 75.6 |
Spain | 17 | 6.3 |
México | 11 | 4.1 |
N/A | 7 | 2.6 |
Argentina | 6 | 2.2 |
Perú | 6 | 2.2 |
United States | 4 | 1.5 |
Venezuela | 4 | 1.5 |
Chile | 3 | 1.1 |
Bolivia | 2 | 0.7 |
Ecuador | 2 | 0.7 |
Aruba | 1 | 0.4 |
Panamá | 1 | 0.4 |
Paraguay | 1 | 0.4 |
Uruguay | 1 | 0.4 |
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In Colombia, most consultations originated in Bogotá (n = 137; 67.2%) and the other four main cities of the country (n = 25; 12.4%); only 2 (0.7%) requests came from remote areas, and the remaining were from intermediate cities (n = 40; 19.7%).
As in many other developing countries, access to adequate health services in Colombia is suboptimal, especially in rural and remote areas. While the main cities have ample infrastructure, the latest technology, and high quality-of-care standards, distant areas of the country are notably underserved.
A number of strategies have been proposed to improve access to health care in order to [
enlarge the capacity overall (eg, increasing entry to medical schools and providing financial or other incentives to physicians to become general practitioners)
maximize the output of existing resources by promoting the formation of multidisciplinary teams to increase access
distribute resources to underserved areas to address inequalities in access
improve specific aspects of access such as waiting times and continuity of care
In Colombia, however, as entry to and graduation from medical school is unregulated, there currently exists an excess of supply of physicians. Nevertheless, the national distribution of the medical workforce is unequal. Moreover, incentives to promote redistribution (general practitioners versus specialists, and location of qualified doctors) have been insufficient to motivate a significant number of professionals to migrate to remote areas.
In this context, the implementation of a teleconsultation service appeared to be an innovative way of delivering health care and advice in Colombia. However, we were aware that important barriers such as limitations in connectivity (79.8 Internet users per 1000 inhabitants) [
Even though no publicity was put in place to encourage its use, in only 6 months a high number of requests have been received, relative to the time elapsed, compared to reports from countries with higher levels of connectivity [
Eysenbach has proposed the law of attrition, which states that in eHealth trials which start with a fixed number of users, usage will decrease because “a substantial proportion of users drop out before completion or stop using the application” [
Use of Doctor Chat: number of requests by month
It has been suggested that possible reasons for patients using the Web in search of health advice include (1) frustration from insufficient or low-quality information previously received (from treating physicians or other sources), (2) failure of previous therapies, (3) preference to remain anonymous, and (4) lack of availability of health services [
By medical specialty, the majority of requests concerned sexual and reproductive health issues, and many contained direct and explicit content; additionally, most users decided to use nicknames to remain anonymous. In this context, and taking into account the general characteristics of the local culture in which sexual-related subjects are still considered taboo, we believe the teleconsultation service encouraged open questioning and facilitated discussion, as the nature of many of the questions posed could have been perceived as socially inappropriate. Furthermore, as most (35%) requests regarding sexual and reproductive health were formulated by users between 18 and 23 years of age, observing the trend over time could be valuable in establishing education campaigns and supporting an exclusive Web-based discussion forum on this theme, targeted at high schools and colleges. This is important in the context of Latin American countries like Colombia and Brazil, where national-level sexual education failures have been reported and pregnancy rates among teenagers continue to rise, thereby increasing poverty among the regions. “Each year of [sexual] education reduces the probability of pregnancy before 20 years of age by 2%” (cited in Spanish in [
Interestingly, we did not encounter any user whose reason for consulting was remoteness or lack of access to health services. As far as we can tell, users came principally from the main cities of Colombia, which have excellent health facilities. This may, to a certain extent, be a reflection of the limited access to the Web in distant areas of the country. Regarding how patients found us and why they would be interested in using our service, we suppose this could have been the result of our high institutional ranking in the country (the second health institution among the top 300 of the country) [
In summary, our experience with Web-based teleconsultation has been positive. Users’ behaviors and perceptions toward the application are encouraging. They actively use the service and perceive it as helpful, and specialists are pleased to share their knowledge. We believe it would be worth the effort to expand and encourage the use of Doctor Chat in distant areas of Colombia and Latin America, as well as homologous applications in other developing countries.
Because “areas...most likely to benefit from telemedicine are those least likely to afford it or to have the requisite communications infrastructure” [
Lastly, we envision Doctor Chat’s future development heading toward supporting isolated health care professionals in remote areas of Colombia. Efforts made by Swinfen et al [
Penetration of mobile phones in Colombia [
The implementation of a Web-based teleconsulting service in Colombia constituted an innovative way to improve community access to health care and information and encouraged open and explicit discussion. Extending the service to underserved areas could improve access to health services and health information and could potentially improve economic indicators such as waiting times for consultations and the rate of pregnancy among teenagers; however, cultural, infrastructural, and connectivity barriers must be resolved before successful implementation can derive population-wide positive impacts. Taking into account the rapid growth and the high penetration of cellular phones in Colombia, making use of this resource could positively impact health care information delivery in the short term.
This research presents many limitations. First, the data analysis required all queries to be subjectively classified into only one of the three schemes described. The classification imposes a categorization bias as there were some multidisciplinary requests. Forthcoming evaluations of Doctor Chat will consider alternative schemes of classification to alleviate this problem. Second, the rural and remote populations for which Doctor Chat was created could not be evaluated. Aside from the lack of marketing and publicity of the site, factors such the low levels of Internet connectivity or the lack of access to computers may have played a major role. Further analysis will aim to address the service’s impact in remote areas. Third, Doctor Chat was not a secure application, and although major efforts have been put in place to provide a high-quality service, issues regarding confidentiality and safety of the users’ information need to be resolved. Last, in spite of the potential of the teleconsulting service to improve access to underserved populations, national and institutional infrastructure need to be extended before its diffusion and implementation on a national or regional scale will be feasible.
We thank the working team at the Division de Educación of Fundación Santa Fe de Bogotá and its Director, Dr. Roosevelt Fajardo, for facilitating the sources, the physical locations, and the time for the preparation of this paper.
JV and AA gathered, analyzed, and interpreted the data and drafted and revised the manuscript. CR and JC contributed to the concept of the report and revised the manuscript. All authors read and approved the final manuscript.
None declared.
General Social Security System for Health (Sistema General de Seguridad Social en Salud
World Health Organization