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 decision, the technology should have been included in the SUS within 180 days from the publication of the incorporation order by the Secretary of Science, Technology, and Strategic Inputs, but to date, the Clinical Protocol and Therapeutic Guidelines making this technology available in the SUS have still not been published. 234 Unfortunately, there are still several gaps in the process of recognizing medical services in telemedicine for the purpose of reimbursement. The example above is the only one deliberated for public health. The process of coding hierarchical classifications or other payment modalities for the various telemedicine services has not yet been properly structured. A more complete and structured set of codes would also provide more accurate data to address the scarcity of systematic economic evaluation of the benefits of telemedicine in both pay-per-service and value-based models. 235 Bridging this gap is essential to guiding public and private health care providers and technology buyers and investors on decisions about investment returns in this field. 4.2. Telemedicine in Supplementary Health In 1988, Brazil opted for the establishment of a universal health care system free and fully accessible, pursuant to art. 196 of the Federal Constitution. However, health care is available to private initiative, as established in the Magna Carta (Paragraph 1 of Art. 199) pertaining to the scope of participation of the private initiative: “Private institutions may participate in a complementary way in the SUS, according to its guidelines, by means of a contract of public law or agreement, with preference given to philanthropic and nonprofit entities.” 236 Supplementary health assists over 47 million beneficiaries in Brazil and is governed by its own legislation, regulated by the National Health Agency. This is a health care system with its own characteristics and regulatory framework guided by specific legislation (Law No. 9.656/1998). The benefits gained from the remarkable development of ICT also apply to supplementary health. However, it should be noted that, due to particularities of laws governing the sector, health care plan operators are required to offer a myriad of procedures included in the List of Procedures and Events in Health of the National Health Agency. 237 Also worthy of note is the fact that when one buys a health care plan, priority is given to access to physicians and therapies that supplement the list of policies offered by the SUS. Most of the supplementary health beneficiaries live in large centers, with over 35 million beneficiaries in the Southeast (28,650,281) and South (6,912,748) regions and more than 18 million in capital cities. An analysis of the intersection of demographic data of supplementary health beneficiaries and Brazilian physicians, including cardiologists, shows that the proportion of physicians per inhabitant (beneficiaries of supplementary health) in these regions is different from the one observed in public health, where truly remote areas receive no coverage. It is imperative to consider that the in-person relationship between physician and patient is the rule in supplementary health, which does not hinder the possibility of making telemedicine resources available. 238 Accordingly, the various services provided by telemedicine are fully applicable to supplementary health. However, the provision of face-to-face consultations with experts rather than their “tele” versions is a legal demand. ICT resources should not be offered to replace face-to-face interaction but should be an option to improve care also in the context of supplementary health. Increased efficiency in health care requires quality improvements and costs savings. 239 The integration of telemedicine into outpatient clinics and hospitals, including supplementary health, can help achieve both goals. 240 Medical care is, without question, one of the most (if not the most) complex sectors in the economy. Considerable financial investment and years of persistence are required to build an effective telemedicine system. The widespread adoption of this type of practice also requires behavioral adaptations by many physicians, organizations, and patients. 241 The industry in this area still requires better regulation. Telemedicine can be an affordable alternative to meet the health needs of vulnerable populations with multiple comorbidities requiring frequent care. 242 Improving patient engagement, telemedicine can provide an effective platform for patients to engage in their own decisions. 243 For example, the US Veterans Health Administration introduced a national telemedicine program named Care Coordination/Home Telehealth. This model allows patients to manage their own conditions, 244 and some important studies have reported that the shared-decision model has reduced hospitalization rates. 245 Unequal access to health, even in supplementary health, is persistent in Brazil and requires major investments to improve the organization of health care systems. Even when health care services and evidence-based guidelines are available for common and relevant conditions like hypertension and diabetes, the implementation gap is vast, and best practices are not absorbed by health care professionals, or recommended measures are not followed by patients and their relatives. The science of implementation has proved to be as important as data analysis in recent decades for the recognition of bottlenecks preventing full use of preventive and therapeutic measures to ensure benefits for patients who can live longer and better by taking advantage of all available knowledge, 246 reducing costs and increasing the efficiency of private health care systems. Direct physician-patient teleconsultation, not yet regulated in Brazil, is the most frequently used model. A US report showed that telecardiology was useful for evaluating both new and recent postoperative referrals, with the potential benefit of knowledge transfer to local primary care. In Canada, teleconsultation has been useful for the evaluation of new patients with syncope and supraventricular tachycardia. 247 In the United Kingdom, a wide range of inpatient and outpatient telecardiology services is available at district hospitals using various technologies. 248 This approach has improved access, was cost neutral, and increased patient satisfaction. The authors emphasized that it complemented but did not replace regular consultations. The demand for home care using web-based applications directed to consumers, including tablet and smartphone 1035