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For more than 26 years now, starting after the publication of the Consensus on Severe Heart Disease in 1993,2the Brazilian Society of Cardiology (SBC) has been regularly issuing guidelines on most diverse topics, guiding the practice of cardiology in Brazil. In 1999, the Brazilian Federal Council of Medicine (CFM)3partnered with the Brazilian Medical Association (AMB) and, aiming to support medical decision making and optimize patient care, started a process along with specialty societies for the development of Medical Guidelines based on current scientific evidence. Thus, the commitment of SBC precedes the initiative by AMB and fulfills one of the society’s objectives, described in the society’s bylaws.  Resolution 1.642/2002,4passed by the CFM to preserve the autonomy of the physician, defined that, in their relationship with physicians and beneficiaries, health insurance and group medical companies, medical cooperatives, self-management companies, and other companies offering direct care or care mediated by medical-hospital services should only adopt medical guidelines or protocols prepared by Brazilian specialty societies along with the AMB. Within this context,5the CFM initiated discussions in 2018 to update the regulations of telemedicine.  Telemedicine can be defined as the application of information and communication technologies to health care with the goal of offering, in a broad concept, health-related services ranging from primary care to robotic surgery and education, expanding coverage to remote areas in a country with continental dimensions.  The Pan American Health Organization (PAHO) and the WHO define telemedicine as “The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.” The PAHO estimates that one third of the population in the Americas has no access to health care and that 800,000 additional health care professionals would be needed to meet the needs in the region.6If applied in its broad context, telemedicine could allow access and reduce inequality for this population by providing supposedly cost-effective quality services, especially considering the increased prevalence and mortality from chronic noncommunicable diseases (NCDs) in low- and middle-income countries like Brazil. Added to this context is the aging and increasing disease rate of the Brazilian population, which makes telemedicine an ideal tool to face the contemporary challenges of universal health care systems.7  Beyond the vast possibilities and applications of telemedicine, rigorous evaluations of telemedicine projects must be undertaken, not only because all health care systems face financial sustainability challenges beyond investments in health care interventions, but also because of the limited clinical evidence available, especially in the current order of value-based medicine. This topic of utmost importance has been the subject of several publications by the WHO. Examples of that include the Digital Health Atlas,8 a global virtual platform to support governments in monitoring and coordinating digital health activities; “BeHe@lthy, BeMobile” (BHBM),9for the prevention and control of NCDs; and mHealth Assessment and Planning for Scale (MAPS), a manual for digital health monitoring and evaluation10to enhance digital health research and implementation; among others. These documents culminated in the publication by the WHO of the first guideline on digital health interventions on April 17, 2019.11  In addition to updating the guideline on telemedicine applicable to cardiology published in 2015, the main objective of the present guideline is to answer the following questions: Is there legal and ethical support for the application of telemedicine in Brazil? Are there technical conditions for the application of telemedicine in the country? What is the priority of incorporating telemedicine into the health care system? For which modalities is there good quality scientific evidence to support this practice? For modalities supported by solid evidence, does cost effectiveness justify this application? What would be the budgetary impact? Is the Brazilian health care system prepared to provide comprehensive care?  This guideline, which is in line with the WHO guidelines,11 advocates that the implementation of telemedicine should be a planned process that provides feasibility of the network coverage in remote locations, elaboration of the legal and judicial bases for its implementation, budgetary impact and cost-effectiveness assessment of each stage of the project, and development of clinical continuum indicators of the applicability for the safety of the beneficiaries. Telemedicine can be a potential tool in improving health care services but is not exempt from risks and challenges related to its implementation and from the evaluation of the real impact of its benefits.  In the final chapter, the authors present a summary of recommendations based on current evidence, in an attempt to guide the discussions that will certainly permeate the democratization of comprehensive health care services, especially the actions involving telemedicine as a tool to expand the universality and integrality of the Brazilian Unified Health System (SUS), recommendations that also extend to supplementary health care.  Brazil, June 2019.  Dr. Marcelo Antonio Cartaxo Queiroga, FESC, TEC-SBC  President-elect of the Brazilian Society of Cardiology (Sociedade Brasileira de Cardiologia - SBC)  Director of the Department of Interventional Cardiology, Alberto Urquiza Wanderley Hospital, Joao Pessoa, PB, Brazil Member of the Paraiba State Academy of Medicine  Dr. Glaucia Maria Moraes de Oliveira, FACC, FESC, TEC-SBC  Associate Professor of Cardiology at the Federal University of Rio de Janeiro (Universidade Federal do Rio de Janeiro - UFRJ)  Coordinator of the Postgraduate Cardiology Program at UFRJ, Rio de Janeiro, RJ, Brazil  President of the Federation of the Cardiology Societies of the Portuguese-Speaking Countries (2015-2016)

Guidelines os the Brazilian Society of Cardiology on Telemedicine in Cardiology - 2019