Tele-echocardiography in paediatrics

Travel Avoidance Using Telepediatric by Patients and Healthcare Providers: a Review of the Literature

Introduction:

Telepediatric is one of the subspecialties of telemedicine that can be defined as the use of information and communication technology tools to offer healthcare services to children at a distance.

Aim:

The use of telepediatric healthcare services for children living in rural or deserved areas may reduce the cost and time of travel to access these services. This study aims to review published papers that assess the percentage of avoided travel or referrals with the use of telepediatric.

Methods:

This is a systematic review study. PubMed database was searched in September 2019 to retrieve the published papers. The final 24 retrieved papers were assessed based on the variables such as modality, referral setting, specialty, continent, weight, and percentage of avoided travel. The multivariate linear regression model was used to estimate the percentage of travel avoidance by telepediatric.

Results:

The linear regression model was determined based on the provided specialty for telepediatric (cardiology, general (multi), and other (rehabilitation, dermatology, psychiatry, respiratory)) with R2 =0.41. The results showed that the mean percentage of avoided travel in cardiology specialty as a baseline was 56%. The use of telepediatric in the general (multi) and other specialties can avoid travel for 26.5% (p=0.02) and 85% (p=0.03) respectively.

Conclusion:

This study showed that telepediatric could reduce travel at least 26.5% and maximal 85%. These results can be used by healthcare providers to decide on the implementation of successful telepediatric systems to reduce referrals.

Telecardiology: Effective Means of Delivering Cardiac Care to Rural Children

Telemedicine allows face-to-face interaction between the medical specialist and the patient. We present our experience of 102 pediatric telecardiology consultations between a tertiary care cardiac center and a remote rural hospital located 120 miles away, between July 2000 and December 2003. The connection was through a Very Small Aperture Terminal satellite bandwidth provided by the Indian Space Research Organization. An S-video link between the echocardiographic and videoconferencing equipment at the remote center allowed the specialist to view images in real time. Pathology was ruled out in 50 (49%) children by tele-echocardiography. Cardiac problems were diagnosed in 52 children (51%), of whom 30 (29%) required surgery. Successful cardiac surgery following telediagnosis was carried out in 18 patients, 8 are awaiting elective operations, and 4 died before surgical correction. The Very Small Aperture Terminal enabled a higher bandwidth that allowed clear images with no significant diagnostic errors. This study demonstrates that pediatric telecardiology effectively delivers cardiac care in rural centers in developing countries with stretched medical resources, where the specialists are urban centered and the majority of patients are rural based.

Narrative review of telemedicine consultation in medical practice

BACKGROUND

The use of telemedicine has grown across several medical fields, due to the increasing number of "e-patients".

OBJECTIVE

This narrative review gives an overview of the growing use of telemedicine in different medical specialties, showing how its use can improve medical care.

METHODS

A PubMed/Medline, Embase, Web of Science, and Scopus search was performed using the following keywords: telemedicine, teleconsultation, telehealth, e-health, and e-medicine. Selected papers from 1996 to 2014 were chosen on the basis of their content (quality and novelty).

RESULTS

Telemedicine has already been applied to different areas of medical practice, and it is as effective as face-to-face medical care, at least for the diagnosis and treatment of some pathological conditions.

CONCLUSION

Telemedicine is time- and cost-effective for both patients and health care professionals, encouraging its use on a larger scale. Telemedicine provides specialist medical care to patients who have poor access to hospitals, and ensures continuity of care and optimal use of available health resources. The use of telemedicine opens new perspectives for patients seeking a medical second opinion for their pathology, since they can have remote access to medical resources that would otherwise require enormous costs and time.

Mobile, cloud, and big data computing: contributions, challenges, and new directions in telecardiology

Many studies have indicated that computing technology can enable off-site cardiologists to read patients’ electrocardiograph (ECG), echocardiography (ECHO), and relevant images via smart phones during pre-hospital, in-hospital, and post-hospital teleconsultation, which not only identifies emergency cases in need of immediate treatment, but also prevents the unnecessary re-hospitalizations. Meanwhile, several studies have combined cloud computing and mobile computing to facilitate better storage, delivery, retrieval, and management of medical files for telecardiology. In the future, the aggregated ECG and images from hospitals worldwide will become big data, which should be used to develop an e-consultation program helping on-site practitioners deliver appropriate treatment. With information technology, real-time tele-consultation and tele-diagnosis of ECG and images can be practiced via an e-platform for clinical, research, and educational purposes. While being devoted to promote the application of information technology onto telecardiology, we need to resolve several issues: (1) data confidentiality in the cloud, (2) data interoperability among hospitals, and (3) network latency and accessibility. If these challenges are overcome, tele-consultation will be ubiquitous, easy to perform, inexpensive, and beneficial. Most importantly, these services will increase global collaboration and advance clinical practice, education, and scientific research in cardiology.

Near real-time echocardiography teleconsultation using low bandwidth and MPEG-4 compression: feasibility, image adequacy and clinical implications

We assessed the feasibility, image adequacy and clinical utility of a tele-echocardiography service which combined video compression with low-bandwidth store-and-forward transmission. Echocardiograms were acquired by a hospital geriatrician, compressed and transmitted using both near real-time (urgent) and delayed (pre-programmed) protocols via an Internet connection to the notebook PC of a remote cardiologist. Clinical utility was evaluated as a change in therapeutic management. During a one-year period, 101 tele-echocardiography consultations were successfully performed (feasibility = 100%) on 95 patients (age 22-95 years), admitted with cardiovascular or neurological diagnoses (24% of the consultations were urgent). In total, 4617 files (1.4 GByte of data) were transmitted, 2669 of which were short video clips. On average, 46 files (13.8 MByte) were transmitted (mean duration 10 min) at each examination. Consultations (both urgent and pre-programmed) were clinically useful in 83% of examinations. Logistic regression analysis showed that both a low left ventricular systolic function and the examination indication were determinants of clinical utility. The transmitted images were considered adequate for diagnosis in 100% of the pre-programmed teleconsultations. Tele-echocardiography using MPEG-4 video compression is a feasible, adequate and clinically useful tool for telemedicine.

Development, implementation, and multicenter clinical validation of the TeleDICOM--advanced, interactive teleconsultation system

There is a need to make medical diagnosis available to critically ill patients on-site, without the necessity of time-consuming and risky transportation to larger reference hospitals. The teleconsultation of medical images is possible with the use of Internet-based TeleDICOM software developed in Krakow, Poland. Interactive consultation between two or more centers offers real-time voice communication, visualization of synchronized Digital Imaging and Communications in Medicine images, and use of interactive pointers and specific calculation tools. If direct interaction between physicians is not needed, the system can also be used in "offline" mode. In 2006, TeleDICOM was successfully deployed in the John Paul II Hospital in Krakow as well as a dozen other cooperating medical centers throughout southeast Poland. It is used for routine referral for cardiosurgical procedures. Aims of the study were to evaluate the image quality, software stability, constant availability, data transmission speed, and quality of real-time synchronized viewing of the images during the TeleDICOM teleconsultation; to evaluate the clinical utility of the TeleDICOM system; and to analyze the compatibility of TeleDICOM with the storage data formats of various imaging machine manufacturers. The analysis of angiographic offline teleconsultations was based on 918 patients referred remotely for coronary artery bypass grafting (CABG). The echocardiographic teleconsultations were performed during 63 live interactive consultations, several of them were presented to live during medical conferences. Measurement tools of the TeleDICOM software were tested against original measurement tools of echocardiographic machines from four different manufacturers. As a result of TeleDICOM consultation, a CABG decision was made in 806 of 918 patients consulted (87.8%). In remaining 12 patients, medical therapy or percutaneous angioplasty was recommended. CABG was performed in 98.6% of the admitted patients. Treatment decisions were changed after admission in 1.4% of patients-however, in all cases, it was not related to analysis of angiography data but rather to the change of clinical condition of the patients. All medical personnel involved in both offline and interactive teleconsultations judged the system positively in all assessed aspects. Lesser scores were observed only in the centers connected by slower networks. Measurements performed in the ECHO-TeleDICOM module were accurate as compared with those performed on a standard echo-machine (correlation r > 0.980, p < 0.001), independently of the echocardiograph model.

CONCLUSION

This study demonstrates that telemedicine can improve patients' management using a clinically effective teleconsultation system. The TeleDICOM system is suited for professional use in the field of cardiovascular disease. It is also prepared for remote live demonstrations of clinical cases during large medical meetings.

Expert visual guidance of ultrasound for telemedicine

Expert visual guidance (EVG) is computer assistance that displays to the examiner how the image plane moves towards (or away from) a desired anatomical location as the ultrasound probe is manipulated over the patient's body. We tested whether EVG by a remote expert could assist inexperienced examiners in acquiring abdominal ultrasound images. The inexperienced examiners were 20 medical students, who were randomly assigned to verbal instruction alone (Group 1) or to EVG (Group 2). The examiners were tested on their ability to visualize the abdominal aorta and the right kidney. Group 2 was more successful in identifying specified anatomy in longitudinal and cross-sectional views of the aorta (95 vs. 75%, P = 0.032) and kidney (98 vs. 88%, P = 0.09). The groups succeeded equally well in obtaining a true cross-sectional view of the aorta. Kidney length was also similar when measured by the two groups. The results demonstrate that an inexperienced ultrasonographer can be significantly assisted by EVG compared to verbal instruction alone. This could be useful for tele-mentoring in rural hospitals as well as for teaching, both in person and at a remote site.

Is cardiac consultation with remote-controlled real-time echocardiography a wise use of resources?

Northern Sweden is a sparsely populated area with six hospitals and about 50 healthcare centers. The elderly population is a large proportion of the total of population, and the incidence of cardiovascular disease is high. The objective of this research was to analyze the costs and benefits of cardiac consultation in healthcare centers involving long-distance, remote-controlled, real-time echocardiography. The distance diagnostics were developed and tested in two healthcare centers. Experiences of the feasibility of this approach were used as a basis for an economic analysis with regard to heart failure. The societal costs for two different systems were calculated, namely, traditional hospital diagnosis versus distance diagnosis using the new system. The potential prime gainers were the patients. Their traveling time, and thereby their time costs, were significantly reduced. The quality of care may also have been improved. From the health authorities' perspective, the costs of the two systems were approximately equal. Since county council costs are not greatly affected, the large reduction in patient travel time and the improved quality of care ought to be a sufficient incentive for large-scale tests.

Post-operative care through tele-follow up visits in patients undergoing thyroidectomy and parathyroidectomy in a resource-constrained environment

We conducted a pilot study to assess the feasibility of tele-follow up in post-operative cases of thyroid and parathyroid diseases. Patients were enrolled after operation at the tertiary hospital in Lucknow who consented to report to the telemedicine centre at Cuttack, approximately 1500 km away. Initially videoconferencing used a single ISDN line (128 kbit/s); subsequently a satellite-based connection (384 kbit/s) was employed. Patients were given a questionnaire to assess their satisfaction with tele-follow up and the financial and work-time savings incurred by them. Over a period of nearly four years, a total of 34 postoperative patients were followed up by telemedicine. A total of 66 tele-visit sessions were held. The average number of visits per patient was two (range 1-6). The nature of disease was benign in 17 patients and malignant in the other 17. The reasons for tele-follow up were: confirmation of histology report (n = 18), medication dosage adjustments (n = 24) and serum thyroglobulin monitoring (n = 5). The patients' level of satisfaction was very good (31%) or excellent (69%). There were substantial financial and work-time savings per visit. Tele-follow up is feasible after thyroid and parathyroid surgery for benign thyroid and parathyroid disorders and in patients with low-risk thyroid cancers. The technique ensures satisfactory postoperative follow-up.

Home videoconferencing for patients with severe congential heart disease following discharge

BACKGROUND

Centralization of pediatric cardiology services into a small number of tertiary centers and the particular stress that accompanies diagnosis and surgical management of severe congenital heart disease (CHD) renders psychological support for families and clinical monitoring of patients following discharge increasingly important. Telemedicine has an increasing role in clinical and academic medicine. Improvements in quality and reliability of videoconferencing systems have allowed this to become a useful diagnostic tool.

OBJECTIVE

This study aimed to assess the benefits of home monitoring by videoconferencing compared with contacting by telephone only, in terms of decreasing anxiety levels and clinical monitoring in the postdischarge period.

METHODS

We performed a prospective, controlled study of children with a recent diagnosis of severe CHD and those recovering from palliative or corrective surgery for severe CHD. We used standardized anxiety scores to assess anxiety after discharge in families followed up by home videoconferencing or telephone calls and assessed the clinical information available through videoconferencing or telephone calls by structured questionnaires.

RESULTS

Videoconferencing decreased anxiety levels compared with telephone calls (P < .05). Improved clinical information was available in the videoconferencing group, resulting in more appropriate and timely hospital attendance.

CONCLUSION

Videoconferencing is acceptable to parents and physicians and provides a more effective form of follow-up in terms of clinical observation and parental anxiety levels.

Diagnosis of congenital heart disease in neonates by videoconferencing: an eight-year experience

Summary

Over an eight-year period, echocardiograms were transmitted by ISDN at 384 kbit/s for a total of 132 patients suspected of having congenital heart disease (CHD). Five transmitted scans were inadequate. Hands-on echocardiograms were performed subsequently on 116 of the remaining 127 cases (91%). Major CHD was diagnosed in 42 of the 116 infants (36%) and minor CHD in 49 (42%). The telemedicine diagnosis was accurate in 97% of the cases (kappa = 0.90). There were four diagnostic errors. Transfer to the regional unit was avoided in 95 patients (72%). The present study shows that high diagnostic accuracy is possible using a telemedicine link to transmit images obtained with the assistance of real-time guidance by a paediatric cardiologist. The results also demonstrate the importance of an expert interpreting the echocardiographic images, since the accuracy of diagnosis was considerably improved (the kappa coefficient increased from 0.14 to 0.90).

One hundred years of telemedicine: does this new technology have a place in paediatrics?

100 years of telemedicine

Telementoring During Endovascular Treatment of Abdominal Aortic Aneurysms:A Prospective Study

PURPOSE

To explore the use of telementoring for distant teaching and training in endovascular aortic aneurysm repair (EVAR).

METHODS

According to a prospectively designed study protocol, 48 patients underwent EVAR: the first 12 patients (group A) were treated at a secondary care center by an experienced interventionist, who was training the local team; a further 12 patients (group B) were operated by the local team at their secondary center with telementoring by the experienced operator from an adjacent suite; and the last 24 patients (group C) were operated by the local team with remote telementoring support from the experienced interventionist at a tertiary care center. Telementoring was performed using 3 video sources; images were transmitted using 4 ISDN lines. EVAR was performed using intravascular ultrasound and simultaneous fluoroscopy to obtain road mapping of the abdominal aorta and its branches, as well as for identifying the origins of the renal arteries, assessing the aortic neck, and monitoring the attachment of the stent-graft proximally and distally.

RESULTS

Average duration of telementoring was 2.1 hours during the first 12 patients (group B) and 1.2 hours for the remaining 24 patients (group C). There was no difference in procedural duration (127+/-59 minutes in group A, 120+/-4 minutes in group B, and 119+/-39 minutes in group C; p=0.94) or the mean time spent in the ICU (26+/-15 hours in group A, 22+/-2 hours in group B, and 22+/-11 hours for group C; p=0.95). The length of hospital stay (11+/-4 days in group A, 9+/-4 days in group B, and 7+/-1 days in group C; p=0.002) was significantly different only for group C versus A (p=0.002). Only 1 (8.3%) patient (in group A: EVAR performed by the experienced operator) required conversion to open surgery because of iliac artery rupture. This was the only conversion (and the only death) in the entire study group (1/12 in group A versus 0/36 in groups B + C, p=0.31).

CONCLUSIONS

Telementoring for EVAR is feasible and shows promising results. It may serve as a model for development of similar projects for teaching other invasive procedures in cardiovascular medicine.