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 Among other barriers to their practical use are the scarcity of resources and technical knowledge, as well as infrastructure issues. Brazil is a country of unequal regional distribution in terms of broadband availability. 7 This means that the infrastructure of the broadband data network is one of the most limiting factors for the expansion of telemedicine in general and telesurgery in particular, especially in rural areas of the country. 3.2. Robotic Angioplasty PCI can be considered a highly predictable, safe, and minimally invasive therapy. However, this manual and operator-dependent procedure must be executed in person, demanding physical action by the physician. Full proficiency can only be achieved in high-volume environments with scenarios involving highly complex and technological interventions. Coronary angioplasty also exposes both professional and patient to ionizing radiation. As a result, the potential risks are high for occupational health damage arising not only from the radiation but also from the need of individual protection 211-213 (e.g., a 7-kg lead apron). Robot-assisted coronary interventions have recently been developed as an alternative to reduce the reliance on manual operation, 214-224 potentially reducing damage from radiation exposure. 225 Clinical studies have demonstrated the safety and efficacy of the robotic system, which has already been approved for routine application in the US and the European Union. Even though the current set of scientific evidence is encouraging, it is also recent and limited to the number of patients treated, hindering further consideration of possible risks and benefits of the technique, especially when it comes to particularities of its application in subgroups of clinical interest. 4. Telemedicine for Provision of Services and in Supplementary Health 4.1. Provision of Services Over 60% of all health care facilities and between 40–50% of all US hospitals are currently estimated to use some form of digital data transmission. 226 In 2016, a US health care facility reported that communication of digital health data (e-mail, phone, and video) exceeded the number of in- person consultations. 227 However, it is important to note that despite new modes and means of communication transmission between physicians and patients, ethical and legal responsibilities remain the same as those governing the traditional physician-patient relationship. 228 Cardiologists must inform their patients about telemedicine services and their limitations, the possibility of late follow-up, by encouraging regular reporting to their attending physicians, and how they can receive electronic health-promoting information. Reimbursement is a key determinant of the success of clinical interventions. The movement toward value-based reimbursement rather than payment for service, which provides incentives for care in lower-cost settings, along with the identification and interaction with high-risk individuals before disease onset, and the efficient use of integrated care teams, provide incentives for telemedicine expansion. Understanding the effect of reimbursement within the context of alternative payment models is a priority. While the path of value-based reimbursement is uncertain, the efficiency of care will inevitably be a priority in any scenario. Ensuring that these technologies are used for patients who meet the appropriate clinical requirements is also an important related topic. In the US, reimbursement for medical services by telemedicine has gradually expanded from coverage of services provided in rural settings to a broader program (Medicare Access and CHIP Reauthorization Act). 229 Training and development projects have been created in Brazil, along with a continuing medical education with special attention to the SAMU/UPA care model, developed by the Ministry of Health and private hospitals. 230 Regarding the payment for telemedicine and telehealth services in Brazil, as already mentioned, it should be considered that the main source of funds has been the public sector: 231-233 • public communications from national (such as the National Council for Scientific and Technological Development – CNPq – and the Financier of Studies and Projects – FINEP) and regional research and innovation funding agencies (state research supporting foundations); • agreements or direct transfer of funds to universities and health departments, within the scope of the program Telessaúde Brasil , then Telessaúde Brasil Redes ; • service providing agreements between public administrators and telehealth centers at university centers; 232 • projects within hospitals receiving tax waiving by the PRO- ADI SUS program from the Ministry of Health. 215 Many of these investments occurred at an early stage of technological development in the country, and only some of the fostered nuclei became active, sustainable services. 232 There is a clear need for inclusion of telehealth procedures in the list of procedures paid by the SUS in order to regulate and encourage their routine use in the health system. Supplementary health, in turn, lacks formal mechanisms of payment and reimbursement for telehealth activities, so telemedicine actions in this sector have been focused on optimizing care and reducing costs, and are often associated with specific conditions like stroke. 231 Of note, the Ministry of Health Secretariat of Science, Technology, and Strategic Inputs, through Ordinance 26, of August 2, 2017, made public the decision to incorporate remote monitoring technology for the evaluation of patients with cardiac implantable electronic devices (CIEDs) within the scope of the SUS. This is an unprecedented incorporation of remote monitoring technology as a result of industry demand. The requester assessed the budgetary impact of the technology over 5 years, considering only direct expenses with the purchase of the remote monitoring device and the provision of conventional monitoring in a base case. A second scenario analyzed a model of dynamic transition state to account for opportunity costs of both technologies, exploring the advantages and disadvantages of each strategy. With the 1034