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 systems on cell phones or monitoring center services have become more frequent due to the development of specialized equipment with direct communication with telemedicine systems such as stethoscopes, scales, thermometers, digital devices, blood pressure equipment, remote monitoring of vital signs and implantable electronic devices. 89,90 Simple watches have been transformed into monitoring systems equipped with technology to report heart rate, stress level (skin humidity and temperature), optical BP, and physical activity, among other parameters. 91-92 Several applications are available to guide the health care team and/or patients, including applications focused on self-care. 89 2.2.2. Decision Support Systems Clinical decision support systems (DSSs) provide knowledge and information from individual patients to physicians and other health care professionals, or to the patients themselves, to improve care quality and clinical outcomes. These systems are recommended by the Community Preventive Services Task Force (CPSTF) in the prevention of cardiovascular diseases despite being based on moderate- to poor-quality evidence. 93 Applications that have shown benefits include those improving screening for cardiovascular risk factors, prescription of aspirin for primary prevention, and counseling on healthy diet, physical activity, and smoking cessation. 94 Due to that, these applications may have wide applicability in PHC. Still, they have shown no evidence of reducing emergency visits, hospitalizations, or cardiovascular events, although additional studies are still needed. A study reported a lower mortality rate with an educational strategy for health care professionals associated with DSS alerts compared with educational strategy alone. 95 DSSs have been evaluated in pilot studies in Brazilian Basic Health Units ( Unidades Básicas de Saúde, UBS) in multifaceted interventions. This tool was proven feasible in PHC in patients with hypertension and diabetes and for cardiovascular risk management, with good satisfaction reported by the professionals and perceived ease of use, 96,97 although the number of questionnaire fields filled in by the professionals was low. 96 This may be related to the incipient implantation of electronic medical records in UBSs, generating duplicate work, a factor that was inversely related to the successful implementation of the DSS. 98 New initiatives are underway to assess the impact on clinical outcomes of the control of patients with hypertension and diabetes in the Mucuri Valley, in Minas Gerais, and the management of patients on warfarin, still the most widely used anticoagulant in the SUS. 2.2.3. Teleconsulting Teleconsulting systems have great applicability in PHC in terms of supporting health care professionals in remote areas and qualifying and reducing the time to diagnosis and treatment. As a tool with the important potential of increasing PHC solvability, teleconsulting should be incorporated into the care process in health care units as an integral part of the regulatory process of the municipality. This is an efficient way to reduce the long wait for in-person consultations with a cardiologist. Although teleconsultation has been extensively studied in our country, 99 only a few studies have evaluated in our population the impact of teleconsultation on traditional health outcomes, like risk and mortality. A systematic review by Liddy et al. 100 reported that teleconsulting systems were highly accepted by patients and health care professionals and improved access to specialized care. A randomized trial in cardiology assessed adverse events (including death, AMI, urgent or emergent cardiac catheterization and/or angioplasty, and emergency room visits) in patients referred to teleconsultation versus patients receiving a traditional referral. The group referred to teleconsultation was more likely to have an appointment with the cardiologist and had fewer visits to the emergency department. 101 2.2.4. Teleregulation The demand for specialized care has been growing worldwide and surpassing the supply of services while meeting limited access to specialists and long waiting times. 101 Interventions in telehealth, particularly involving teleconsultation for regulation, have shown a great impact in reducing waiting time with the qualification of access to specialists, avoiding unnecessary referrals, and at a lower cost. In Brazil, the experience of teleconsultation for regulation (or teleregulation) has also reduced the waiting time for specialized consultation, qualifying the access and optimizing the use of resources, in addition to providing users with greater comfort and lower impact on their routine. 102-104 Teleregulation also enables the classification of the risk of the demand for specialized care. Protocols to guide health care have been established, and the final decision regarding referral is defined along with the attending and teleconsulting physicians. In addition to the mentioned gains from the user’s perspective, there is the process of continuing education and professional qualification, increasing solvability in primary care. 101-104 2.2.5. Telediagnosis Tele-electrocardiography, the most common activity in telecardiology, is a simple and low-cost technology for easy transfer of a small file using an Internet connection with limited bandwidth. Thus, it can be easily incorporated into the PHC routine for its great applicability and suitability for the infrastructure of PHC facilities in remote and poor areas. 105,106 Tele-electrocardiography is widespread in both public and private settings in Brazil, with several companies in the country delivering reports around the clock. In 2017, the Ministry of Health launched the National Offer of Telediagnosis Project ( Projeto Oferta Nacional de Telediagnóstico, ONTD) to expand the diagnostic services of tests conducted remotely in the most deprived areas of the country. Tele-electrocardiography was the first modality of telediagnosis offered nationwide by a telehealth team specialized in telecardiology. This project is an innovation in the management of a large-scale national telemedicine project model, and the good results obtained have shown its easy applicability and suitability for remote areas. 107 The application of AI to the large databases of diagnostic tests improves the ease of the process of reporting and increases the accuracy of the tests. 61,108 1024