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 to Primary Care.” In the project, the analysis of the economic sustainability of the application of telehealth in primary care was based on a comparison of costs between two scenarios: I. Face-to-face care: when the patient is treated in primary care and requires to be subsequently referred to secondary level care; II. Remote care: when the primary care physician receives remote support through a telehealth service, and this support avoids the referral of the patient. The results refer to 20 municipalities participating in the National Telehealth Project with reliable data, located in the North/Northeast regions and Jequitinhonha Valley in Minas Gerais, considered one of the poorest regions of the state. The main results of the project are shown in table 5.4. 279,280 This project presented more realistic results compared with the previous one, as it collected information about the cost of patient referral directly in the municipalities. However, it maintained the sample of the participating municipalities concentrated in the same region of the state, the Jequitinhonha Valley, which has a low human development index (HDI). In 2009, the Minas Telecardio Expansion project expanded the service to higher HDI regions for a final sample of 66 other municipalities. The results were similar to those of the previous project and are shown in table 5.5. 281-283 Recently, a study (pending publication) was conducted to assess the cost effectiveness of the ONTD. The ONTD is a project of the Ministry of Health to offer telecardiology services (ECG reports and teleconsultations) to all Brazilian states, for which the CTS HC/UFMG was chosen as Specialist Center, that is, the service provider. State Telehealth Centers receive funding from the Ministry of Health to train and implement care in municipalities of their state, previously agreed with the State Health Departments, which may forward 24/7 their test requests and teleconsultations to the Expert Center. The requests may be elective or urgent. The report is available on a platform, and, when necessary, local physicians can ask questions as part of teleconsultation. An alert system informs Table 5.5 – “Economic Analysis and Impact of the Application of Telehealth Services in Primary Care in Municipalities of Minas Gerais” 282 Average cost of each telehealth activity in 2010 R$ 10.68 Average fixed cost of patient referral R$ 41.77 Savings to the municipality by avoided referral R$ 71.11 Minimum monthly number of referrals reduction per municipality to enable the system 4.28 Minimum monthly number of activities per municipality to enable the system 5.5 Average monthly number of activities by municipality in 2010 28.5 Investment by SES/MG (2005-2009) R$ 11,599,638.00 Savings for the health care system (from June 2006 to July 2011) R$ 31,970,549.13 Return on Investment (ROI) (savings:investment) 2.76:1 % of referrals avoided 78% Minimum referral distance for system viability (approximate) 54 Km Average cost of each telehealth activity in 2010* R$ 10.68 *ECG report, case discussion and teleconsultation. Table 5.4 – Comparison of average costs (R$/month/municipality) between face-to-face and remote care in the project “Analysis of Financial Management of Telehealth Services Applied in Primary Care” 279,280 Cost item (R$/month) Face-to-face care Remote care Patients referral 2,399.58 697.78 System implementation 56.03 Equipment depreciation in the municipality 101.97 Equipment maintenance in the municipality 40.79 Capital cost of equipment 51.92 Activities of remote care* 210.80 Total 2,398.58 1,159.29 *ECG report, case discussion and teleconsultation. physicians and nurses about critically emergent situations. The effectiveness of the system has been proven by performance indicators (time to submit tests, waiting time for analysis of urgent/elective reports, time to the first analysis of the report, number of tests requested by the municipality, etc.), and user satisfaction. The results proved the effectiveness of the system by replacing alternatives previously available to obtain the test/report (referral of the patient, periodic visits of the cardiologist to the municipality, and outsourcing of tests to private companies/clinics). In terms of these alternatives, the cost of the test by the ONTD is about five times lower, demonstrating cost effectiveness. 5.7. Analysis of the Economic Impact of the TelessaúdeRS Teleconsulting Service An economic analysis of the TelessaúdeRS service was performed to evaluate the financial results of the service generated to the state. Teleconsultations are offered for various specialties, in addition to the contribution to the regulation of waiting lists for the state of Rio Grande do Sul. Teleconsultations in endocrinology, gastroenterology, proctology, rheumatology, and urology were selected as samples. The cost per teleconsultation (R$ 110.29) was evaluated considering data from 8 months of service and included costs of the physical structure of the service (rent, energy, depreciation, server capacity, among others) and payment of professionals. As a premise, all teleconsultations and regulations that resulted in the cancellation of the face-to-face consultation would represent, for the state, savings in patient transportation to Porto Alegre (which is variable according to the municipality of origin) and payment of face-to-face consultation to the municipality (R$ 100.00). Estimated savings were calculated 1043