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 of planning and implementing AI regulation in this area. Also, the European Union has published a document on the ethical aspects of AI in health care. 63 The fast-paced digital transformation has led to reflections on how to balance the adoption of technology and emerging digital systems with ethical, moral, emotional, and social values, particularly values related to patients’ safety. 2. Uses and Application of Telemedicine in Cardiology 2.1 Telemedicine in Brazil With the development of the Information Society in the late 20 th century as a result of globalization and widespread use of ICT, the emergence of organizational, social, political, and economic innovations of the society became pressing issues, requiring new ways to learn, teach, and work. The world began to worry about the principles of equal opportunity, participation, and integration so that everyone could access and benefit from the applications of the Information Society. In health care, telemedicine has made substantial progress worldwide, as it is classically viewed as a set of actions with great potential to improve access to health care services and to care quality and effectiveness at a lower cost. 65 As a mark of the new millennium, we highlight the aging of the population, the increase in chronic noncommunicable diseases, and the consequent need to provide health care services for a longer time, which increases health-related costs. Therefore, it is essential to incorporate innovative, efficient, and effective solutions like telemedicine and biotechnology to promote universality and comprehensiveness in health care. Several actions in telemedicine are currently present in all continents and must be planned according to local needs in order to be successful. According to Bashshur et al., 66 the success of these actions depends on three pillars: access, quality, and cost. 66 In developed countries, telemedicine is an alternative to traditional methods and is already present as an option to supplementary health or to address gaps in the health care system, but always aiming at integral care. In developing countries, access is the main pillar, since telemedicine can be the only option in regions where traditional specialized care is not available. In Brazil, the systematic development of telemedicine and telehealth in the public health system started in 2006, with investments from the Ministry of Health, State Health Secretariats, and Municipal Health Secretariats. The main objective was to support primary care, particularly the Family Health Strategy in remote municipalities, through teleconsulting, telediagnosis, and tele-education. If applied on a large scale, these strategies could decrease the referral of patients to large centers and consequently improve the population’s access to specialized care and reduce health care costs. 67 Therefore, telemedicine in the Brazilian public system has been anchored from the outset in the basic principles of universality, equity, and integrality of the SUS. Based on the universality principle, health is everyone’s right, and it is up to the state to ensure it. Equity targets the reduction of inequalities or increased investment in areas where it’s most needed. Integrality considers the individual as a whole to meet all his or her needs. 68 Telecardiology, one of the most developed domains in telemedicine, has multiple actions in promoting health, disease prevention, diagnosis, treatment, and rehabilitation with an impact on the quality of life. It can be considered an important ally of the public, supplementary, or private health care system in promoting comprehensive and high-quality health care. 2.2. In Primary Care Primary Health Care (PHC) involves integrated and multidisciplinary care and is the foundation to achieve universal health, according to the PAHO, which also advocates for other health determinants like education, food, housing, financial protection, clean water, and safe environments. 69 To achieve universal health, health care systems must be transformed, especially by making PHC efficient, integrated, and organized, placing the patient at the center of the system. The PAHO also estimates that about one third of the population in the Americas has no access to health care and that 800,000 additional health care professionals would be necessary to meet the needs in the region. Telemedicine plays an important role in the qualification of the PHC, with clinical, human, organizational, educational, administrative, technical, and social benefits. 70 The application of telemedicine to support PHC brings benefits to the population served, including (i) improved access to specialized services, (ii) increased solvability to the basic level, (iii) decreased number of patients referred to other municipalities for specialized care, (iv) more qualified referrals and faster hospitalization decisions, (v) better training of local health care professionals, with consequently better qualified clinical care, (vi) reduced time to diagnosis, with decreased risk of complications, (vii) diagnosis of diseases at earlier stages, (viii) cost and time savings for the patient, (ix) improved quality of life, (x) fewer hospitalizations and visits to emergency units, (xi) improved clinical care continuum, (xii) reduced risk factors and complications from chronic diseases, and (xiii) savings for the health care system. 70-74 2.2.1. Applications in Health Promotion and Prevention In cardiology, health promoting actions and primary and secondary prevention of cardiovascular diseases translate into significant cost savings by reducing specialized consultations, hospitalizations for clinical complications, and admissions to the emergency room. 71 Telemedicine can be useful in controlling risk factors for coronary artery disease; improving blood pressure control; 75-78 reducing glycosylated hemoglobin levels in patients with diabetes mellitus; 79-81 improving lipid profile; 82,83 reducing weight, body mass index (BMI), or waist circumference in obese individuals; 77,84-86 and increasing the success of smoking cessation programs. 87 Several modalities of telemedicine can be applied in this regard, including cell phone text/audio messaging systems, which have positive results in improving medication adherence, changing eating habits, and increasing physical activity among patients with hypertension, diabetes, and obesity, or after acute myocardial infarction (AMI). 86,88 24-hour monitoring 1023