ABC | Volume 114, Nº1, January 2019

Viewpoint Barberato & Queiroga Echoes of Telecardiology Guideline Arq Bras Cardiol. 2020; 114(1):130-132 Echocardiography as a cardiovascular imaging modality directly depends on the appropriate acquisition and interpretation of satisfactory images. There are no studies conclusively comparing image quality by tele-echocardiography and traditional echocardiography. In parallel, there is no scientific evidence to conclude that the use of tele- echocardiography in primary health care in remote locations is able to reduce morbidity and mortality in the community compared to traditional care workflow. Obviously, the advent of digital health, which encompasses the use of telemedicine as a useful complementary tool to allow equity of access to health for all Brazilians, is a desirable novelty in the current scenario. 16 Considering the continental dimension of Brazil, we could assume that populations living in remote areas would benefit from state investment in the spread of digital health. We must welcome the changes that digital transformation can trigger in the practice of medicine, especially where the integrality of access to health is not contemplated. However, such changes should be supported by consistent scientific evidence that accredits them as real advancement, avoiding inappropriate use of new technologies. 17 There are potential advantages of adopting tele- echocardiography in public healthcare of underprivileged populations in distant locations, but the method still lacks robust scientific validation with prospective controlled studies confirming the health benefits of patients. In addition, a broad discussion on the need for investment in digital technology infrastructure, cost-effectiveness, budgetary impact, regulation and legal certainty, among other challenges and risks, is crucial. It is important to remember that Brazilian law: (a) authorizes only physicians to perform and interpret echocardiograms in the country, and (b) recognizes echocardiography as an area of ​activity of cardiology and pediatrics. Regulatory debate involving authorities, professional councils and medical societies is mandatory before tele-echocardiography is incorporated into public health policies in Brazil. In the area of ​supplementary health, there is no legal backing for non-medical individuals, even under the supervision of physicians, to perform echocardiograms, and the use of tele- echocardiography by other health professionals would be a practice not covered by law. 18 In addition, there is currently no provision for reimbursement for any of the procedures used in Telemedicine, which are not part of the Procedures and Health Events Roll of the National Health Agency. Table 1 lists the potential advantages and challenges for the implementation of tele-echocardiography in Brazil. Author contributions Conception and design of the research: Barberato SH, Lopes MACQ; Writing of the manuscript: Barberato SH. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associatedwith any thesis or dissertationwork. Table 1 – Potential advantages and main challenges for the adoption of tele-echocardiography in Brazil Potential advantages Main challenges Allow access to the method at remote locations Lack of standardization of tele- echocardiography components and proper internet coverage Early diagnosis and therapy guidance Uncertainty whether image quality and diagnostic accuracy is comparable to traditional method Potential optimization of clinical outcomes Lack of scientific evidence proving impact on clinical outcomes Reducing the cost of transporting human resources to geographically distant areas Absence of scientific evidence showing cost-effectiveness; questions about budget impact and system reimbursement Reducing the cost of transporting patients to tertiary centers Uncertainty about adherence by local health professionals Reduction in the number of unnecessary echocardiograms Prohibition of Brazilian law to the performance of echocardiography by non-medical operators (sonographers) Prioritization and organization of waiting lists in healthcare systems with limited availability of specialized exams and consultations Lack of guidelines for operator training Forensic insecurity No current laws regarding licensing, data storage, privacy and confidentiality 1. Barberato SH, Romano MMD, Beck ALS, Rodrigues ACT, Almeida ALC, Assunção BMBL, et al. Position Statement on Indications of Echocardiography in Adults - 2019. Arq Bras Cardiol. 2019;113(1):135-81. 2. Lopes MAC, Oliveira GMM, Ribeiro ALP, Pinto FJ, Rey HCV, Zimerman LI, et al. Diretriz da Sociedade Brasileira de Cardiologia sobre Telemedicina na Cardiologia – 2019. Arq Bras Cardiol.2019;113(5):1006-56 3. Singh S, Bansal M, Maheshwari P, Adams D, Sengupta SP, Price R, et al. American Society of Echocardiography: Remote Echocardiography with Web-Based Assessments for Referrals at a Distance (ASE-REWARD) Study. J Am Soc Echocardiogr. 2013;26(3):221-33. 4. Arbeille P, Chaput D, Zuj K, Depriester A, Maillet A, Belbis O, et al. Remote Echography between a Ground Control Center and the International Space References 131