Telecardiology: potential impact on acute care

Telehealth for Pediatric Cardiology Practitioners in the Time of COVID-19

Due to the COVID-19 pandemic, there has been an increased interest in telehealth as a means of providing care for children by a pediatric cardiologist. In this article, we provide an overview of telehealth utilization as an extension of current pediatric cardiology practices and provide some insight into the rapid shift made to quickly implement these telehealth services into our everyday practices due to COVID-19 personal distancing requirements. Our panel will review helpful tips into the selection of appropriate patient populations and specific cardiac diagnoses for telehealth that put patient and family safety concerns first. Numerous practical considerations in conducting a telehealth visit must be taken into account to ensure optimal use of this technology. The use of adapted staffing and billing models and expanded means of remote monitoring will aid in the incorporation of telehealth into more widespread pediatric cardiology practice. Future directions to sustain this platform include the refinement of telehealth care strategies, defining best practices, including telehealth in the fellowship curriculum and continuing advocacy for technology.

A practical guide to graphic communication for quality assurance, education, and patient care in echocardiography

Graphic communication (GC) is useful for continuous quality improvement (CQI), education, and patient care when in‐person discussion is not possible because of geographic and schedule constraints. In echocardiography, these constraints can be mitigated by (a) capturing screenshots and device photos or videos and sharing them by email or text message, (b) simultaneous viewing of images on digital displays, and (c) broadcasting the study real time during acquisition to other mobile or stationary devices. Screenshots are useful for CQI and education and can be acquired, annotated, and shared with minimal impact on the flow of clinical echo interpretation. Providers at different locations can employ GC for shared clinical decision making by viewing echo studies from the same server, video conferencing or accessing real‐time broadcast from a device. Which GC tool is selected is determined by its ease of use, the provider's goals and whether immediate image review is needed.

ANMCO/SIT Consensus Document: telemedicine for cardiovascular emergency networks

Telemedicine has deeply innovated the field of emergency cardiology, particularly the treatment of acute myocardial infarction. The ability to record an ECG in the early prehospital phase, thus avoiding any delay in diagnosing myocardial infarction with direct transfer to the cath-lab for primary angioplasty, has proven to significantly reduce treatment times and mortality. This consensus document aims to analyse the available evidence and organizational models based on a support by telemedicine, focusing on technical requirements, education, and legal aspects.

Application of Handheld Tele-ECG for Health Care Delivery in Rural India

Telemonitoring is a medical practice that involves remotely monitoring patients who are not at the same location as the health care provider. The purpose of our study was to use handheld tele-electrocardiogram (ECG) developed by Bhabha Atomic Research Center (BARC) to identify heart conditions in the rural underserved population where the doctor-patient ratio is low and access to health care is difficult. The objective of our study was clinical validation of handheld tele-ECG as a screening tool for evaluation of cardiac diseases in the rural population. ECG was obtained in 450 individuals (mean age 31.49 ± 20.058) residing in the periphery of Chandigarh, India, from April 2011 to March 2013, using the handheld tele-ECG machine. The data were then transmitted to physicians in Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, for their expert opinion. ECG was interpreted as normal in 70% individuals. Left ventricular hypertrophy (9.3%) was the commonest abnormality followed closely by old myocardial infarction (5.3%). Patient satisfaction was reported to be ~95%. Thus, it can be safely concluded that tele-ECG is a portable, cost-effective, and convenient tool for diagnosis and monitoring of heart diseases and thus improves quality and accessibility, especially in rural areas.

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.

Impact of telemedicine on hospital transport, length of stay, and medical outcomes in infants with suspected heart disease: a multicenter study

BACKGROUND

Previous single-center studies have shown that telemedicine improves care in newborns with suspected heart disease. The aim of this study was to test the hypothesis that telemedicine would shorten time to diagnosis, prevent unnecessary transports, reduce length of stay, and decrease exposure to invasive treatments.

METHODS

Nine pediatric cardiology centers entered data prospectively on patients aged <6 weeks, matched by gestational age, weight, and diagnosis. Subjects born at hospitals with and without access to telemedicine constituted the study group and control groups, respectively. Data from patients with mild or no heart disease were analyzed.

RESULTS

Data were obtained for 337 matched pairs with mild or no heart disease. Transport to a tertiary care center (4% [n = 15] vs 10% [n = 32], P = .01), mean time to diagnosis (100 vs 147 min, P < .001), mean length of stay (1.0 vs 26 days, P = .005) and length of intensive care unit stay (0.96 vs 2.5 days, P = .024) were significantly less in the telemedicine group. Telemedicine patients were significantly farther from tertiary care hospitals than control subjects. The use of inotropic support and indomethacin was significantly less in the telemedicine group. By multivariate analysis, telemedicine patients were less likely to be transported (odds ratio, 0.44; 95% confidence interval, 0.23-0.83) and less likely to be placed on inotropic support (odds ratio, 0.16; 95% confidence interval, 0.10-0.28).

CONCLUSIONS

Telemedicine shortened the time to diagnosis and significantly decreased the need for transport of infants with mild or no heart disease. The length of hospitalization and intensive care stay and use of indomethacin and inotropic support were less in telemedicine patients.

"Initiate-build-operate-transfer"--a strategy for establishing sustainable telemedicine programs in developing countries: initial lessons from the balkans

Establishing sustainable telemedicine has become a goal of many developing countries around the world. Yet, despite initiatives from a select few individuals and on occasion from various governments, often these initiatives never mature to become sustainable programs. The introduction of telemedicine and e-learning in Kosova has been a pivotal step in advancing the quality and availability of medical services in a region whose infrastructure and resources have been decimated by wars, neglect, lack of funding, and poor management. The concept and establishment of the International Virtual e-Hospital (IVeH) has significantly impacted telemedicine and e-health services in the Balkans. The success of the IVeH in Kosova has led to the development of similar programs in other Balkan countries and other developing countries in the hope of modernizing and improving their healthcare infrastructure. A comprehensive, four-pronged strategy, "Initiate-Build-Operate-Transfer" (IBOT), may be a useful approach in establishing telemedicine and e-health educational services in developing countries. The development strategy, IBOT, used by the IVeH to establish and develop telemedicine programs, was discussed. IBOT includes assessment of healthcare needs of each country, the development of a curriculum and education program, the establishment of a nationwide telemedicine network, and the integration of the telemedicine program into the healthcare infrastructure. The endpoint is the transfer of a sustainable telehealth program to the nation involved. By applying IBOT, a sustainable telemedicine program of Kosova has been established as an effective prototype for telemedicine in the Balkans. Once fully matured, the program will be transitioned to the national Ministry of Health, which ensures the sustainability and ownership of the program. Similar programs are being established in Albania, Macedonia, and other countries around the world. The IBOT model has been effective in creating sustainable telemedicine and e-health integrated programs in the Balkans and may be a good model for establishing such programs in developing countries.

Healthcare's ascension to patient-centered genomic care

The future of healthcare in the 21st century will be patient-centered genomic care. These two previously disparate fields now stand to help revolutionize the way in which we provide healthcare. Preventative medicine guided by genomic information and patient preference will enable further reductions in common chronic diseases, especially with the significant aging population. This care will increasingly involve corporate genomics companies and services to accomplish evidence-based medicine and patient-centered delivery. The goal of this advanced care should be 'the care we need and no less, the care we want and no more'. Armed with genomic knowledge and healthcare coaching, patients of the 21st century will be prepared to reduce disease burden and improve healthcare satisfaction through active partnerships with healthcare practitioners and complementary technology. Anything less cannot truly be patient-centered genomic medicine.

A review of smart homes- present state and future challenges

In the era of information technology, the elderly and disabled can be monitored with numerous intelligent devices. Sensors can be implanted into their home for continuous mobility assistance and non-obtrusive disease prevention. Modern sensor-embedded houses, or smart houses, cannot only assist people with reduced physical functions but help resolve the social isolation they face. They are capable of providing assistance without limiting or disturbing the resident's daily routine, giving him or her greater comfort, pleasure, and well-being. This article presents an international selection of leading smart home projects, as well as the associated technologies of wearable/implantable monitoring systems and assistive robotics. The latter are often designed as components of the larger smart home environment. The paper will conclude by discussing future challenges of the domain.

Validation of Remote Cardiopulmonary Examination in Patients With Heart Failure With a Videophone-Based System

BACKGROUND

The aim of this study was to evaluate feasibility and accuracy of a videophone-based system for remote cardiopulmonary examination of patients with heart failure.

METHODS AND RESULTS

Fifty patients were examined by 2 cardiologists, 1 with a conventional stethoscope and 1 remotely with a videophone-based method, employing an electronic stethoscope and transmitting through an integrated services digital network line. During both sessions, the cardiologists filled out a 27-item questionnaire, which was then compared; concordance between standard and remote examination was evaluated. In 92% of patients, electronic and acoustic auscultation concurred. Only in 3 patients (4%) did teleauscultation not permit a correct interpretation of lung examination. In one patient, bilateral fine crepitant rales were not detected during teleauscultation. Conversely, in the second, patient bilateral fine crepitant rales were recognized during teleauscultation, which were not confirmed during real-life auscultation. In the third nonconcordant patient, moderate-degree wheezing was not detected during teleauscultation. Fine crepitant rales were present at the lungs lower fields in 12 and wheezing in 3 additional patients, and were always correctly identified during teleauscultation. Overall, sensitivity, specificity, positive, and negative predictive value of remote lung auscultation were 88%, 97%, 94%, and 94%, respectively.

CONCLUSIONS

Remote cardiopulmonary examination appears as a feasible method for assessing patients with heart failure. Telestethoscopy can therefore be reliably used in the context of comprehensive telecare programs.

Videoconferencing for a Veteran’s Pain Management Follow-Up Clinic

The under treatment of pain has been well documented. Contributing to this is the limited availability of pain management specialists in many geographic areas. The use of technology to provide care to underserved areas is gaining momentum. We chose to study whether stable patients and staff in chronic pain clinic were satified with the use of a videoconferencing format in care delivery. Our goals were to determine whether patients and staff could successfully operate the extant videoconferencing equipment, was the equipment dependably functional, was the use of a videoconferencing format an acceptable method of healthcare delivery for both patients and staff, whether patients and staff were satisfied with the process, and whether this was a cost-effective mode of care delivery. Thirty-six patients were enrolled over 29 months. Questionnaires were administered to staff and patients. Routine pain clinic patient assessment tools were administered. Results showed the use of videoconferencing for this group of patients is useable and satisfactory for both patients and staff, that the patients save time and money, and that for a system where videoconferencing equipment is already in use, it is also cost effective. Staff were able to identify new patient problems. Some patients would prefer to be seen in person but find that the savings in time and money override this preference. Hearing impaired patients have difficulty using this medium. Dependable equipment and phone connections are needed. A videoconferencing clinic format is a clinically acceptable and cost effective method for follow-up of stable patients with chronic pain.

Forward and store telemedicine using Motion Pictures Expert Group: a novel approach to pediatric tele-echocardiography

BACKGROUND

Live transmission of echocardiograms over integrated services digital network lines is accurate and has led to improvements in the delivery of pediatric cardiology care. Permanent archiving of the live studies has not previously been reported. Specific obstacles to permanent storage of telemedicine files have included the ability to produce accurate images without a significant increase in storage requirements.

OBJECTIVE

We evaluated the accuracy of Motion Pictures Expert Group (MPEG) digitization of incoming video streams and assessed the storage requirements of these files for infants in a real-time pediatric tele-echocardiography program.

RESULTS

All major cardiac diagnoses were correctly diagnosed by review of MPEG images. MPEG file size ranged from 11.1 to 182 MB (56.5 +/- 29.9 MB).

CONCLUSIONS

MPEG digitization during live neonatal telemedicine is accurate and provides an efficient method for storage. This modality has acceptable storage requirements; file sizes are comparable to other digital modalities.

Feasibility of remote echocardiography with satellite transmission and real-time interpretation to support medical activities in the austere medical environment

Echocardiography is an essential tool in the evaluation of patients with cardiac emergencies and chest trauma. The objective of our study was to establish the feasibility and diagnostic accuracy of a portable satellite transmission system in the assessment of cardiac emergencies for the real-time support of mass casualty and humanitarian relief efforts. Twelve patients with various degrees of cardiac structural disease identified by conventional inhospital transthoracic echocardiography were transported to a remote portable field hospital where transthoracic echocardiography was performed with a handheld echocardiographic device. Images were then relayed by a commercial satellite to a level III trauma center where they were interpreted in real time by a cardiologist. Remote studies were recorded at the field hospital before satellite transmission and again on download at the receiving facility. The remotely acquired studies before and after satellite transmission were compared with each other and subsequently compared with conventional hospital transthoracic echocardiograms for technical quality and diagnostic accuracy using a blinded, single-reader, side-by-side comparison. Excellent agreement was found between the recorded field-site and satellite-transmitted images with an overall average of 95% concordance. When the field data acquired with the handheld device and satellite transmission were compared with conventional inhospital echocardiography, a high degree of agreement was demonstrated in overall technical quality (83%) and assessments of left ventricular ejection fraction (100%), pericardial effusion (100%), and left ventricular size (92%). This study demonstrates the feasibility and diagnostic accuracy of remote, real-time echocardiography using satellite transmission for mass casualty triage or humanitarian relief efforts.

Impact of telemedicine on the practice of pediatric cardiology in community hospitals

BACKGROUND

Tele-echocardiography has the potential to bring real-time diagnoses to neonatal facilities without in-house pediatric cardiologists. Many neonates in rural areas, smaller cities, and community hospitals do not have immediate access to pediatric sonographers or echocardiogram interpretation by pediatric cardiologists. This can result in suboptimal echocardiogram quality, delay in initiation of medical intervention, unnecessary patient transport, and increased medical expenditures. Telemedicine has been used with increased frequency to improve efficiency of pediatric cardiology care in hospitals that are not served by pediatric cardiologists. Initial reports suggest that telecardiology is accurate, improves patient care, is cost-effective, enhances echocardiogram quality, and prevents unnecessary transports of neonates in locations that are not served by pediatric cardiologists.

OBJECTIVE

We report the largest series to evaluate the impact of telemedicine on delivery of pediatric cardiac care in community hospitals. We hypothesized that live telemedicine guidance and interpretation of neonatal echocardiograms from community hospitals is accurate, improves patient care, enhances sonographer proficiency, allows for more efficient physician time management, increases patient referrals, and does not result in increased utilization of echocardiography.

METHODS

Using desktop videoconferencing computers, pediatric cardiologists guided and interpreted pediatric echocardiograms from 2 community hospital nurseries 15 miles from a tertiary care center. Studies were transmitted in real-time using the H.320 videoconferencing protocol over 3 integrated services digital network lines (384 kilobits per second). This resulted in a frame rate of 23 to 30 frames per second. Sonographers who primarily scanned adult patients but had received additional training in echocardiography of infants performed the echocardiograms. Additional views were suggested as deemed necessary by the interpreting physician, and interpretations were made during the videoconference. The results of the echocardiogram and recommendations for patient care were communicated to the referring physician over the telemedicine system. Analyses of accuracy, patient treatment, echocardiogram quality, time to diagnosis, pediatric cardiologist practice time management, patient referral patterns, and echocardiography utilization were conducted prospectively.

RESULTS

A total of 500 studies in 364 patients were transmitted during a 30-month period. The most common indication for echocardiography was to rule out congenital heart disease (208 of 500 studies). Signs and symptoms that prompted this concern included cyanosis, murmur, tachypnea, genetic syndrome, arrhythmia, abnormal fetal echocardiogram, and maternal diabetes. Other indications included suspected patent ductus arteriosus (PDA; 182 of 500 studies), intracardiac clot or catheter position, persistent pulmonary hypertension, and hemodynamic instability. Cardiac diagnoses included complex congenital heart disease (n = 16), noncritical heart disease (n = 107), and PDA (n = 86). Additional diagnoses included persistent pulmonary hypertension (n = 12), septal hypertrophy (n = 18), right atrial mass/clot/vegetation (n = 11), and decreased cardiac function (n = 6). An umbilical venous catheter was visualized in the left atrium in 9% (45 of 500) of all studies. No significant abnormalities were found in 244 studies. Major diagnoses were confirmed by subsequent review of videotape in all studies. Comparison of final videotape interpretation to initial telemedicine diagnosis resulted in 1 minor diagnostic change (membranous versus inlet ventricular septal defect). Echocardiograms were performed in subsequent visits in 264 patients. The diagnosis was altered in 3 patients. Telemedicine had an immediate impact on patient care in 151 transmissions. The most common interventions were indomethacin treatment for PDA (n = 76), retraction of umbilical venous catheters from the left atrium (n = 45), inotropic or anticongestive therapy (n = 19), anticoagulation (n = 8), and prostaglandin infusion (n = 8). Nineteen patients were transported to our hospital because of the telemedicine diagnosis. Inpatient or outpatient cardiology follow-up was recommended in an additional 131 studies and did not result in any change in the initial management. The most common diagnoses in these patients were ventricular septal defect (n = 56), atrial septal defect (n = 21), septal hypertrophy (n = 9), intracardiac thrombosis (n = 8), and pulmonary valve stenosis (n = 4). We speculate that the immediate availability of an echocardiographic diagnosis likely prevented unnecessary transport in 14 cases. Recommendations for additional views or adjustment of echocardiography machine settings were made in 95% of transmissions. Real-time guidance was especially helpful in suprasternal notch and subcostal sagittal imaging. Depth, color Doppler sector size, and color Doppler scale were frequently adjusted from routine adult settings during the teleconference. The average time from request for echocardiogram to completion of the videoconference was 28 +/- 14 minutes. This was significantly shorter than the waiting time (12 +/- 16 hours) for the videotape to be delivered by courier. Telemedicine eliminated the need for consultation in 194 cases and allowed the cardiologist to delay the visit until the end of the day in an additional 26 cases. This resulted in average time savings of 4.2 person-hours/wk based on travel and consultation time. Utilization of echocardiography was similar before (35 of 1000 births) and after (33 of 1000 to 43 of 1000) telemedicine installation. The percentage of neonatal echocardiograms that were interpreted by our practice increased from 63% to 81% at 1 hospital and from 0% to 100% at the other hospital.

CONCLUSION

Real-time transmission of neonatal echocardiograms from community hospitals over 3 integrated services digital network lines is accurate and has the potential to improve patient care, enhance echocardiogram quality, aid sonographer education, and have a positive impact on referral patterns and time management without increasing the utilization of echocardiography.