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 with the ability to optimize search and exchange of information and the use of images by specific software programs. DICOM specifications are updated from time to time without losing sight of previously established functionalities. 184,185 2.8.2. MRI, CT, and Telemedicine Contrast-enhanced magnetic resonance imaging (MRI) and computed tomography (CT) scanning bear additional complexities, requiring specific care at centers performing these tests. These range from the scheduling of the tests – in which there is a need to define its precise indication, e.g. , pharmacological stress test (dipyridamole, adenosine, dobutamine), evaluation of myocardial ischemia, viability, valvular heart disease, specific cardiomyopathies, among others – to the need of on-site physicians due to frequent use of contrast and medications, nursing technicians to obtain an adequate venous access, and biomedical doctors and technologists with specific training and experience in the acquisition and postprocessing of MRI and CT scan images using software dedicated for these analyses. The images should be read by experienced specialized physicians with specific training in that particular area of diagnostic imaging. Such training usually requires 2 years and is not widely available nationwide, limiting the number of trained specialists for appropriate MRI and CT scanning. The complexity of performing MRI and CT scans with remote guidance and reading, together with the need for specialists to analyze the images and the possibility of the test being performed at any given time, depending on the clinical indication, makes telemedicine increasingly important for this activity. 2.8.3. The Federal Council of Medicine and Tele-CT/Tele- MRI In 2014, the CFM updated the rules for tele-CT/tele-MRI practice in Brazil. 186 These rules are valid for the transmission of patients’ images between different locations to produce a medical report, a second expert opinion, or a clinical imaging review. The rules related to the topic of this document are listed below: • Clinical data – The transmission of tests by tele-CT/tele- MRI should be accompanied by necessary clinical data of the patient, collected by the requesting physician, for the preparation of the report. • Patient authorization – The patient must authorize on an informed consent form the transmission of images and data. • Local and remote specialist – The responsibility for the remote transmission of tests and reports must be assigned to a specialist in MRI and CT scanning. • Limits for remote practice – In the case of noncontrast imaging ( e.g. , calcium score – CS), and in the absence of a specialist physician at the health care facility, the attending physician may ask the specialist for appropriate remote diagnostic support. • Specialist required – A specialist physician must be present in centers where contrast imaging tests – including MRI and CT scans – are performed. • Shared responsibility – The professional responsibility for the care lies with the specialist physician caring for the patient undergoing the test. The specialist issuing the remote report shares this responsibility. • Headquarters in Brazilian territory – Legal entities providing services in tele-CT/tele-MRI must be headquartered in Brazilian territory and be registered with the CRM of their jurisdiction. If the provider is an individual, he or she must be a physician trained in MRI and CT scanning. • Operating standards – This is beyond the scope of this document, but specific information can be found in another document on operating standards and minimum requirements for the transmission and handling of remote imaging diagnostic reports. • Image compression and transmission – Communication protocols, file formats, and compression algorithms should comply with current DICOM and HL7 standards. The specialist physician is responsible for evaluating the compression ratio. • Image visualization and processing – The specialist physician is responsible for ensuring the technical characteristics of remote workstations, monitors, and ergonomic conditions in order to avoid compromising the diagnosis. • Safety and privacy – Computerized systems used for the transmission and handling of clinical data and diagnostic imaging reports and for sharing of image and information must comply with CFM regulations. Specifically, tele-CT/ tele-MRI, systems must meet the mandatory requirements of the “Level of Safety Assurance 2 ( Nível de Ga rantia de Segurança 2, NGS2)” established in the current Certification Manual for Electronic Health Registration Systems issued by the CFM and the Brazilian Society of Health Informatics ( Sociedade Brasileira de Informática em Saúde , SBIS). 2.8.4. Imaging Transmission Imaging transmission must comply with CFM standards regarding quality and security. However, MRI and CT images are generally larger, requiring an infrastructure with adequate data bandwidth for transmission. Importantly, the specialist physician responsible for the report must download the images. Thus, the choice of important sequences after image acquisition and the method of compression are fundamental for a smooth flow. 2.8.5. Postprocessing Software and Workstations Ranging from ECG images to three-dimensional coronary angiotomography (TCA) images and the wide variety of MRI sequences, several imaging parameters must be evaluated, most requiring specific software. Assessment of CS – CS is assessed with software programs installed in workstations, which are usually purchased with the CT equipment, or with other independent programs or plug- ins. The report usually informs the amount of calcification in each artery along with the total CS value and percentile for the patient’s gender and age, based on several population studies, of which the most used and recommended is the MESA (MultiEthnic Study of Atherosclerosis) study. 187,188 Other data 1031