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 There were 55.9 million deaths worldwide in 2017 in an estimated world population of 7.64 billion people. 23 Of these, 70% were due to NCDs, and are expected to continue to increase in the coming decades, especially in low- and middle-income countries, even though all-cause mortality has decreased, notably due to the reduction of infant and child mortality of children under 5 years, stabilization of mortality from 5 years to 49 years and increase in life expectancy. 23 The increase in NCDs is expected with the aging of the population, with the control of communicable diseases and with the increase of premature mortality in individuals from 30 to 70 years of age. 24 In Brazil, NCDs were responsible for about 60% of deaths in 2017, according to the Department of Informatics of the Unified Health System (DATASUS), 25 noting that this group of diseases shares the same risk factors and social determinants. The severity of the issue is large enough to set targets for 30% reduction of premature mortality by NCDs as part of the Sustainable Development Goals (SDG) for 2030. 26,27 It is also believed that one-third of the populations of the Americas do not have access to health care, and that an additional 800,000 health workers would be needed to meet the demands of health systems in the region. 28 The combined approach to NCDs and their risk factors was considered a cost-effective package by WHO, requiring investment of USD 1 per capita in low-income countries, USD 1.5 in low-middle-income countries, and USD 3 in average income countries, underscoring the importance of joint study of NCDs. 29 According to the WHO Director-General, Dr. Tedros Adhanom Ghebreyesus, “leveraging the power of digital technologies will be essential to achieving the Global Sustainable Development Goals, including universal health coverage, and that such technologies are no longer a luxury, but a necessity”. He also suggests that we make sure that innovation and technology alleviate inequalities, and that countries must be guided by evidence to establish harmonized digital systems, and not be seduced by the novelties. 30 The World Health Assembly resolution on Digital Health, unanimously adopted by WHO Members in May 2018, demonstrated collective recognition of the value of digital technologies in contributing to the advancement of universal health coverage, with an emphasis onNCDs, and recommended that health ministries evaluate the use of digital technologies dedicated to health, prioritizing development, evaluation, implementation and increased use of these technologies, as well as guiding their standardization, including through the promotion of digital health interventions. However, it was pointed out that, in order to reduce health inequalities, a rigorous evaluation of eHealth strategies would be necessary in order to generate evidence and promote the appropriate integration of the use of these technologies. 18 Recommendations of the Telemedicine Directive of the Brazilian Society of Cardiology for cardiovascular health To guide the practice of Telemedicine in CVD, Lopes et al. developed the Telemedicine Directive of the Brazilian Society of Cardiology, 31 with the objective of discussing legal and ethical support, technical conditions and priority for implementation, cost-effectiveness and budget impact for the use of Telemedicine for the cardiovascular health of the Brazilian population. It was found that there is space for Telemedicine initiatives as a specialist matrix support for general practitioners and family health doctors in basic health units in remote areas of the Brazilian territory, especially with regard to diagnostic methods, avoiding unnecessary displacements with additional burden to the health system. The clinical and economic results obtained with public policies focused on digital health in Brazil suggest that technologies that allow patient monitoring (telemonitoring) and the issuance of remote reports (Telediagnosis) applied to cardiology can be cost-effective, with an acceptable impact on the public budget. However, the set of scientific evidence in Brazil is still limited, given the small number of patients involved, to infer that the application in subgroups of clinical interest should be generalized. The benefits of this technology could be equally applicable to supplemental health in Brazil, even in the face of a diverse regulatory framework, and of the appropriate coverage of face- to-face social assistance. It should be noted that the majority of the beneficiaries of supplementary health reside in larger centers, where the ratio of doctors/specialists per inhabitant is appropriate, and consultations in person are a legal imposition. Telemedicine may be an important incremental tool in supplemental health, provided there is additional regulation for its implementation. Among the possible measures to extend the scope of Telemedicine in supplementary health, as already exists in American Medicare, would be the inclusion of technologies, with scientific and legal basis, in theHealth Procedures and Events List of theNational SupplementaryHealth Agency, since coverage would be mandatory, providing equity and legal certainty. It is recommended that the bases established by the Brazilian Code of Medical Ethics be maintained in the Telemedicine and Telecardiology procedures. Telemedicine should be considered an additional tool for the face-to-face physician-patient relationship, without ever replacing it. Conclusion Telemedicine as a means of increasing universal and integral access to health, backed by solid evidence, attested by the scientific community, within the budgetary capacity of the Brazilian State, expressed in legitimate public policies, integrates the existential minimumof each Brazilian citizen. It is, therefore, a universal right and duty of the State, and must be guaranteed through social and economic policies in force in the country. The remarkable advance of information and communication technologies and their application in health must be a constant focus of attention of the public authorities, being an instrument of equity and fostering the dignity of the human person. The use of technology in medicine emphasizes the duty of due care to preserve patients’ privacy and the transcendent values that underlie the practice of Medicine. Author contributions Conception and design of the research, Acquisition of data, Analysis and interpretation of the data, Writing of 432