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 1.6.3. Regulation of Telemedicine by the Federal Council of Medicine According to CFM Resolution 1.643/2002, 37 telemedicine is the practice of medicine through the use of interactive audiovisual and data communication methodologies, with the objective of health care, education, and research. Additionally, the following relevant aspects should be highlighted: • The services provided must have appropriate technological infrastructure and should comply with the CFM technical standards related to data storage, handling, transfer, confidentiality, and privacy, and must ensure professional secrecy. • The professional responsibility for the care lies with the patient’s attending physician. Others involved in the process will be jointly liable to the extent to which they contribute to the eventual damage. • Entities providing telemedicine services must be registered in the Entities Register of the Regional Council of Medicine of the state of their location along with a physician regularly registered in the Council assigned as a technical manager and a list of all physicians participating as staff members. Since then, technological innovations and the democratization of Internet access have allowed several innovations that still lack proper regulation, such as: • new means of physician-patient relationship; • emergence of data and service agents and providers; • discussion of a new format for the free and informed consent form under strict safety rules to guarantee information confidentiality and integrity. This scenario prompted a need to update the regulation of telemedicine practice in Brazil. Based on that, the CFM issued Resolution 2.227/2018, which was later repealed. However, an update of the Resolution is urgently needed to provide legal security within the perspective of telemedicine emerging as a vector of health transformation. 38 In this guideline, we adopt the denomination of the services offered within the scope of telemedicine, according to the Ministry of Health Ordinance 2.546, dated October 2011, and current CFM regulation. 1.7. Applicability in Brazil In a country with continental proportions like Brazil, telemedicine represents a perspective to ensure the implementation of public policies conceived when the SUS was established, which have not been entirely fulfilled due to existing unassisted or remote areas lacking health care professionals, among other reasons. Thus, infrastructure conditions must be established to deliver available resources using health-related ICTs to these areas. To understand the applicability of telemedicine in Brazil, it is important to discuss concepts related to remote areas and to know the country’s medical demography. 1.7.1. Concept of Urban andRural Territories andRemote Area The definition of territory goes beyond that of physical space since it generally has a strong relationship with the sociocultural context of the area. The division between urban and rural spaces is not abrupt; both have flexible boundaries and similar characteristics. 39 Territorial occupation is evidently unequal in many regions, as it is also the access to goods and services offered in different forms of human settlements. In general, modes of transport and accessibility to urban and rural areas differ from one location to another, thus the importance of defining a classification for urban and rural concepts. 40 According to the Organization for Economic Cooperation and Development (OECD), spaces are classified according to the population density, the proportion of the population living in large centers, and accessibility, defined as the commuting time between urban centers and rural areas. A rural area is classified as remote by the OECD when 50% of the local population requires at least 45 to 60 minutes of travel in motor vehicle to reach a center with a population of at least 50,000 inhabitants. 41 In Brazil, the classification of occupied rural or urban spaces was established in 1938 by Decree No. 311/1938. The 2014 Territorial Base Manual, by the Brazilian Institute of Geography and Statistics (IBGE), 42 considers the access by national road or waterway network from rural areas to urban centers to classify rural areas according to their degree of proximity and access to large urban centers, creating a sense of isolation. The 2014 Transportation Logistics Map classified municipalities as adjacent or remote if the travel time from the municipal headquarters to a center of influence was longer or shorter, respectively, than the national average. Table 1.1 shows the distribution of municipalities across the national territory based on the classification of isolation by IBGE. 43 More than 65% of the municipalities considered to be remote are located in the North and Midwest regions of the country. These two regions concentrate 5 million inhabitants or 72% of the country’s residents living in remote municipalities (almost 7 million individuals live in areas considered remote by the IBGE). Also in the North and Midwest regions, the population in remote municipalities represents 20% and 12% of the total population, respectively. Figure 1.1 shows the proportion of urban population in Brazilian municipalities. 1.7.2. Medical Demography The ratio of physicians per inhabitant in Brazil (2.1 physicians per thousand inhabitants) is significantly lower than the average ratio in OECD countries (3.4 physicians per thousand inhabitants). In addition to the absolute shortage of professionals, the country also has relative shortages due to large regional inequalities in the distribution of the existing medical workforce. Recent studies point out to a large concentration of medical professionals in the South and Southeast, with the proportion of specialists following this trend. 45 Table 1.2 shows the distribution of physicians by country region, divided according to specialization as generalists, with some type of specialty (specialists), ratio per thousand inhabitants, and distribution of cardiologists by region and per inhabitant. In the North and Northeast regions, some Federation units have a physician/inhabitant ratio below 1.00, like 1017