ABC | Volume 113, Nº3, September 2019

Viewpoint Lopes et al Digital health, universal right, duty of the State? Arq Bras Cardiol. 2019; 113(3):429-434 CFM, there is an offer by specialized companies, especially in the scope of supplementary health, with the imperative need by such companies of their own administrative act. In this sense, the CFM issued Resolution CFM 2.227/2018, 12 published in the Brazilian Federal Official Gazette on February 6, 2019, to update the current discipline. The resolution aimed to guarantee security to the provision of medical services mediated by information and communication technologies in Brazil. There is no doubt of the need to update the regulatory framework that disciplines the participation of doctors in the so-called Telemedicine. This measure legitimizes the doctor‑patient relationship in the field of digital health. However, there was an avalanche of questions from the medical category about the form and merit of this standard. In their article Window to the future or door to chaos? , Lopes et al. 13 discussed several aspects related to the legality and timeliness of Resolution CFM 2.227/2018, and the allowing of Teleconsultations was the most challenging question, precisely due to the flexibility of prescription without the direct examination of the patient, a conduct that is prohibited by the Brazilian Code of Medical Ethics.* For the authors, the regulation of CFM “should therefore represent a step forward, not a setback. Broadening access to public health is a common desire of all doctors. The major challenge of Resolution CFM 2.227/2018 would be having the effectiveness and applicability to move forward in the field of justice and deliberative ethics”. The avalanche of corporate questions from the medical category, among other reasons, motivated the revocation of this Resolution by CFM. 11 Thus, the use of telemedicine by doctors in Brazil must occur according to the provisions of Resolution CFM 1.643/2002. 10 It is noteworthy that there were problems in communication regarding the contents of the norm, generating an intense reaction from doctors in relation to the merit of the regulation. In addition, as discussed by Lopes et al., 13 CFM could not delegate exclusively to specialty societies the prerogative of developing guidelines on Telediagnosis. It is important to emphasize that Law 12.401, dated April 28, 2011, 9 defines that the elaboration of clinical protocols and therapeutic guidelines within SUS is a jurisdiction of the National Commission for the Incorporation of Technologies in SUS (Conitec). Therefore, CFM could not, on the basis of a normative resolution, exclude those who have legal jurisdiction to elaborate guidelines within the Brazilian health system, delegating this attribution exclusively to private entities, even if conditioned to their approval. Hence, whether in relation to Robotic Telesurgery or Telediagnosis, the revoked Resolution could be improved. Difficulties for the implementation of digital health as a duty of the State In this sense, we could imagine Telemedicine as a useful complementary tool to allow fair access to health for all Brazilians, regardless of ethnicity, gender, socioeconomic status and location in the national territory. It could be assumed, especially if we consider the continental dimension of Brazil, that populations living in remote areas would benefit from the State’s investment in the dissemination of digital health. According to the Brazilian Institute of Geography and Statistics (IBGE), 14 about 65% of the municipalities located in remote areas are located in the North and Midwest regions of the country. On the other hand, the study Demografia Médica no Brasil (Medical Demography in Brazil, 2018) 6 reported significant inequality in the distribution of doctors, who are predominately located in the large urban agglomerations of the South and Southeast Regions, which also concentrates the largest number of specialists, with he North and Northeast Regions having a lower medical/inhabitant density. If we also look at the issue from the perspective of care, through the National Register of Health Establishments (CNES) 15 of the Brazilian Ministry of Health, we can observe a greater concentration of medical activity in the Southeast and South Regions. It is also important to mention that there is a lower concentration of networks linked by fiber optics in municipalities in the North Region, and that mobile cellular telephone coverage for the Brazilian population is between 98 and 99%, with a higher concentration in the urban centers of the Southeast and South regions. 16,17 It is understood that, although the demand formedical services in remote areas is an opportunity, the provision of Telemedicine services to these areas presents a great implementation challenge similar to the universal access to traditional health services. The expansion of Telemedicine would have to be preceded by improved digital technology infrastructure. On the other hand, through the International Telecommunication Union (ITU), 18 the United Nations has been working with the World Health Organization (WHO) to stimulate the reduction of the global digital divide, with the e-health strategy, focused on digital health, via Telemedicine. Investments in digital health have generated a number of WHO publications. Examples are the Digital Health Atlas, 19 a virtual global repository to support governments in monitoring and coordinating digital investments, BeHe@lthy, BeMobile (BHBM), 20 for prevention and control of NCDs, mHealth Assessment and Planning for Scale (MAPS), a manual for monitoring and evaluation of digital health, 21 aimed at strengthening the research and implementation of digital health, and the first WHO Digital Health Interventions Guideline. 22 The latter document 22 suggests that most of the available scientific evidence on the benefits of implementing global digital health is still not robust, and that there are numerous gaps for large-scale use, albeit in a complementary way to traditional methods. The WHO recommends that a planned process should take place, including: the feasibility of network coverage for access to remote locations, the construction of the legal framework for its implementation, the budget impact and the cost-effectiveness evaluation of each stage of the project's implementation, with the elaboration of indicators of the clinical continuum of applicability for the safety of users. Telemedicine to reduce inequalities in the approach to NCDs Telemedicine, if applied in its broad context, could allow access and equity, offering quality services with supposed cost-effectiveness, especially considering the increase in the prevalence and mortality of NCDs, of which cardiovascular diseases (CVD) are its main component. 431