ABC | Volume 113, Nº5, November 2019

Guidelines Guideline of the Brazilian Society of Cardiology on Telemedicine in Cardiology – 2019 Arq Bras Cardiol. 2019; 113(5):1006-1056 Presentation In due time, the Brazilian Society of Cardiology decided to create a guideline on telemedicine applied to cardiology, also known as telecardiology. According to the Pan American Health Organization (PAHO) and the World Health Organization (WHO), telemedicine is “The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.” Such a seemingly simple and altruistic definition carries a wide range of potential implications at various levels, from an ethical point of view to a potential impact on clinical practice and outcomes. Hence, the importance of guidelines, organized by the medical community through scientific societies, in offering to all of those involved in the process a reference based, as much as possible, on expert opinion, current scientific evidence, and on respect for medical ethical and deontological values. Considering that cardiovascular diseases are the main cause of morbidity and mortality in the 21st century in Brazil and worldwide, the opportunity to use instruments to allow more effective actions in the prevention, diagnosis, treatment, and follow-up of these diseases paves the way to very relevant perspectives of better care for the populations and communities that we serve. At the same time, bioethical aspects and consequences should never be neglected, as they can (and should) undermine programs that, disguised as “medical,” fail to meet these ethical requirements. Therefore, regulated operating models based on guidelines organized by medical-scientific authorities are fundamental in striking a balance. The introduction and implementation of new digital technologies are favoring the emergence of new methodologies (many still experimental) aimed at improving the capacity of intervention on individual patients and allowing for more customized care. We are experiencing what Eric Topol 1 in his latest book, “Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again,” called the “Fourth Industrial Age” comprising artificial intelligence, robotics, and big data that will have a great impact on the way we live and see ourselves as human beings. If this is very positive at first sight, it is also true that it is not devoid of risk, particularly in the way that we approach or will approach the patient. Therefore, one must not forget the Hippocratic principle: “It is far more important to know what person the disease has than what disease the person has.” In fact, when we are sick, we all want to have our doctor – and not a computer – taking care of us and offering us a word of comfort and confidence. Therefore, we must think smartly about how to apply to human benefit this impressive array of elements that have opened up frontiers that were unfathomable just a few years ago. Telemedicine – or telecardiology – can indeed play a very important role, particularly when this may be the only available resource. However, its use must be properly delineated to prevent abuse and misuse. The present document and guideline was prepared for this purpose. This complete document offers a detailed review of the regulation of telemedicine in Brazil, defines the meaning of a geographically remote area, and describes the fundamentals of telemedicine and the secure grounds for its transmission. This document also offers up-to-date information on current evidence and applications of so-called teleconsultation, telediagnosis, and telemonitoring, and reflects on how telemedicine can provide technology-based medical services, with artificial intelligence playing a key role. The document also includes the economic assessment and budgetary impact of incorporating telemedicine in cardiology in Brazil and telemedicine in supplementary health, and – in one of the most important chapters – presents the ethical and legal aspects of telemedicine. Finally, the document includes a set of recommendations intended to be practical and adapted to the Brazilian perspective. The result is a guideline perfectly aligned with the WHO guidelines on the principle that the implementation of telemedicine must be properly planned and should predict situations like the feasibility of network coverage for technology access in remote locations, construction of a legal and judicial structure for the implementation, budgetary impact and cost-effectiveness assessment of the implementation of each stage of the project, and development of indicators of the clinical continuum of applicability for user safety. As the president-elect of the World Heart Federation, I see this as a model document in terms of how it was planned and implemented, as well as in its content, reflecting the current evidence and perspective of the main scientific players in the area. As such, I think it will become a historical document, a milestone in the responsible introduction of telemedicine-telecardiology in clinical practice, in this case, applied to Brazil, but which can serve as an example for others globally, contributing to decrease the burden of cardiovascular diseases worldwide. Lisbon, June 2019. Prof. Fausto J. Pinto, FESC, FACC President-elect, World Heart Federation (WHF) Past President, European Society of Cardiology (ESC) University of Lisbon, Portugal 1012