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 as the difference between the cost of performing canceled teleconsultations and the cost of face-to-face care. The analysis identified that over 21 months (October 2016 to June 2018), the state saved R$ 2,287,121.78, of which 47% were related to consultations and 53% to transportation services. For teleconsultation, the service was found to be attractive up to the amount of payment per consultation of R$ 38.95, considering the average cost of transportation. The municipalities with the greatest distances from Porto Alegre had higher savings, except for four municipalities neighboring Porto Alegre, which had a higher number of avoided teleconsultations than the others’ average. Of note, a comparison of these results with those of other states and services should consider that the services of Telessaúde are provided by scholars and “CLT” professionals (employees following the Brazilian Labor Laws); therefore, Telessaúde can operate at a lower cost per teleconsultation. The operation of a similar service including only “CLT” employees would increase the cost per each teleconsultation and require additional economic analysis. The WHO considers cost effective those interventions with ICER between 1 and 3 times the gross domestic product per capita per life-year, unless adjusted for QALY. 6. Recommendations The Brazilian Society of Cardiology, due to the growing interest in the use of telemedicine for the expansion of health care, particularly in the area of cardiology, prepared this guideline to inform the medical category and society in general on the scientific and technological basis of telemedicine applications considering the current scenario. Even though there is growing enthusiasm for the democratization of information and communication technologies, it is important to point out that barriers to implementation persist across the country and must be addressed. The most significant ones are: • update of laws and regulations applicable by the health authorities and CFM; • provision of minimum telecommunications infrastructure in health care facilities, especially in remote areas; • cost of technology; • need for qualification and training of human resources; • incorporation of technologies in the SUS’ public policy list and in the List of Procedures and Events in Health of the National Health Agency. By bringing to light the discussion about telemedicine applications, in addition to its media repercussion, we seek to provide scientific and technical support for the elaboration of health care policies consistent with the use of this technology. In this sense, we must formally incorporate, after due evaluation by the CONITEC, the various possibilities available today linked to the respective clinical protocols and therapeutic guidelines (PCDT). Also, in the context of supplementary health, it is necessary to include in the List of Procedures and Events in Health of the National Health Agency those with scientific recognition and authorized for current use in the country. As discussed in this guideline, with rare exceptions, there is no provision in the Brazilian Hierarchical Classification of Medical Procedures (which is a condition for inclusion in the NHA coverage list) for common procedures in telemedicine. Generic coding is used, with descriptions that are broad in nature and allow for likelihood use, such as code 2.01.01.20-1 (clinical and electronic evaluation of a patient with a cardiac pacemaker or resynchronization defibrillator or defibrillator). However, the reimbursement of this service will depend on the health care provider’s sole decision. This fact limits the applicability of telemedicine in the field of supplementary health, with the related consequences. In 2015, the Brazilian Society of Cardiology, through the Telecardiology Guideline for the Care of Patients with Acute Coronary Syndrome and other Heart Diseases, 133 made recommendations on this topic. However, the current version of the broader guideline addresses new applications for telecardiology, especially those already incorporated into the health care system. It still deals with future perspectives, such as the use of telerobotics and AI. The authors, focusing on current scientific evidence and cost effectiveness, have updated the recommendations to guide public and private health care providers on judicious use of telemedicine applications in Brazil. Table 6.1 summarizes the recommendations outlined in this guideline. 1044