Telecardiology and its settings of application: An update

Exploring the challenges to using telecardiology as perceived by pre-hospital emergency care personnel: a qualitative study

BACKGROUND

Today, using the medical technology of telecardiology, as part of advanced medical services, plays an essential role in providing care to cardiac patients in life-threatening conditions who need emergency care. However, pre-hospital emergency care personnel are faced with certain challenges in using telecardiology, with adverse effects on their performance. Therefore, the present study aimed to investigate the challenges to using telecardiology as viewed by pre-hospital emergency care personnel in Southern Iran.

METHODS

The present study is a qualitative work of research with a content analysis approach. Selected using purposeful sampling, 19 pre-hospital emergency care personnel were interviewed on a semi-structured, personal, in-depth basis. The qualitative data obtained were analyzed using the Graneheim and Lundman's conventional content analysis approach (2004).

RESULTS

Based on the qualitative data analysis, 3 themes and 8 subthemes were obtained. The three main themes included professional barriers (lack of clinical knowledge of telecardiology, lack of clinical skill in telecardiology, violation of patients' privacy, lack of clinical guidelines on telecardiology), medical equipment and telecommunication barriers (poor reception and ineffective means of communication, low charge on the battery of tele-electrocardiogram machines), and organizational management barriers (serious lack of cardiologists available for medical counseling and lack of continual personal development of the telecardiology personnel).

CONCLUSION

Senior managers in pre-hospital emergency care services are recommended to use the results of this study to identify the influential factors in using telecardiology and take the necessary measures to eliminate the existing barriers toward making optimal use of telemedicine, thereby improving the quality of care provided for cardiac patients.

Management of Coronary Artery Disease in Older Adults: Recent Advances and Gaps in Evidence

Coronary artery disease (CAD) is highly prevalent in older adults, yet its management remains challenging. Treatment choices are made complex by the frailty burden of older patients, a high prevalence of comorbidities and body composition abnormalities (e.g., sarcopenia), the complexity of coronary anatomy, and the frequent presence of multivessel disease, as well as the coexistence of major ischemic and bleeding risk factors. Recent randomized clinical trials and epidemiological studies have provided new data on optimal management of complex patients with CAD. However, frail older adults are still underrepresented in the literature. This narrative review aims to highlight the importance of assessing frailty as an aid to guide therapeutic decision-making and tailor CAD management to the specific needs of older adults, taking into account age-related pharmacokinetic and pharmacodynamic changes, polypharmacy, and potential drug interactions. We also discuss gaps in the evidence and offer perspectives on how best in the future to optimize the global strategy of CAD management in older adults.

Cardiology in a Digital Age: Opportunities and Challenges for e-Health: A Literature Review

To date, mortality rates associated with heart diseases are dangerously increasing, making them the leading cause of death globally. From this point of view, digital technologies can provide health systems with the necessary support to increase prevention and monitoring, and improve care delivery. The present study proposes a review of the literature to understand the state of the art and the outcomes of international experiences. A reference framework is defined to develop reflections to optimize the use of resources and technologies, favoring the development of new organizational models and intervention strategies. Findings highlight the potential significance of e-health and telemedicine in supporting novel solutions and organizational models for cardiac illnesses as a response to the requirements and restrictions of patients and health systems. While privacy concerns and technology-acceptance-related issues arise, new avenues for research and clinical practice emerge, with the need to study ad hoc managerial models according to the type of patient and disease.

Virtual Cardiology: Past, Present, Future Directions, and Considerations

Purpose of Review

Through this review, we attempt to explore the role of telemedicine and virtual visits in the field of cardiology pre-COVID-19 and during COVID-19 pandemic, their limitations and their future scope for delivery of care.

Recent Findings

Telemedicine, which rose to prominence during COVID-19 pandemic, helped not only in reducing the burden on the healthcare system during a time of crisis but also in improving patient outcomes. Patients and physicians also favored virtual visits when feasible. Virtual visits were found to have the potential to be continued beyond the pandemic and play a significant role in patient care alongside conventional face-to-face visits.

Summary

Although tele-cardiology has proven beneficial in terms of patient care, convenience, and access, it comes with its fair share of limitations-both logistical and medical. Whilst there remains a great scope for improvement in the quality of patient care provided through telemedicine, it has shown the potential to become an integral part of medical practice in the future.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12170-023-00719-0.

The Italian Society of Cardiology and Working Group on Telecardiology and Informatics 2023 updated position paper on telemedicine and artificial intelligence in cardiovascular disease

In 2015, the Italian Society of Cardiology and its Working Group on Telemedicine and Informatics issued a position paper on Telecardiology, resuming the most eminent evidence supporting the use of information and communication technology in principal areas of cardiovascular care, ranked by level of evidence. More than 5 years later and after the global shock inflicted by the SARS-CoV-2 pandemic, an update on the topic is warranted. Recent evidence and studies on principal areas of cardiovascular disease will be therefore reported and discussed, with particular focus on telemedicine for cardiovascular care in the COVID-19 context. Novel perspectives and opportunities disclosed by artificial intelligence and its applications in cardiovascular disease will also be discussed. Finally, modalities by which machine learning have realized remote patient monitoring and long-term care in recent years, mainly filtering critical clinical data requiring selective hospital admission, will be provided.

Remote Consultations in General Practice - A Systematic Review

INTRODUCTION

Remote consultations in general practice can be very useful form of telemedicine, which is basically a way to exchange medical information to improve the clinical health of patients when the patient and their general practitioner (GP) are not on the same place at the same time. This concept was developed in the 1980s to provide health care to patients who lived in remote areas.

METHODS

We were interested in researching what kind of remote consultations are available in general practice and what is the usage of these methods. We used four keywords - remote consultation and general practice or family medicine or primary care - and we searched in four different scientific databases: Medline-PubMed, Scopus, Web of Science and IEEX Xplore.

RESULTS

We used a PRISMA diagram to identify studies and search the four main databases, we investigated 48 full text articles and when we applied our inclusion and exclusion criteria, 12 studies were included in this systematic review.

CONCLUSIONS

This systematic review covers the topics of remote consultation versus a traditional or classic physical consultation. Studies have shown its importance prior to the COVID-19 pandemic, and its value while in the mist of the pandemic then caring for infected patients. We have found that remote consultation is necessary, but it must be an improvement on the previous system. Teleconsultations can reduce the number of visits, especially during lockdown situations, with both patients and GPs satisfied with the method, but we should not forget that a physical consultation cannot be fully replaced by a remote consultation due to the limitations of the latter.

Differences in Treating Patients with Palpitations at the Primary Healthcare Level Using Telemedical Device Savvy before and during the COVID-19 Pandemic

Background: Palpitations are one of most common reasons why a patient visits a general practitioner (GP) and is referred to a cardiologist. Coronavirus disease 2019 (COVID-19) has been associated with new-onset arrhythmias, which are difficult to diagnose at the primary healthcare level during pandemic-related lockdown periods. Methods: A total of 151 patients with a complaint of heart rhythm disorder were included from before and during the COVID-19 pandemic, as well as after the start of vaccination, in this cohort retrospective study. We used a telemedical device—namely, a personal electrocardiographic (ECG) sensor called Savvy—to investigate heart rhythm in patients. The primary outcome of the study was to evaluate the number of actual heart rhythm disorder patients and any differences that infection with or vaccination for COVID-19 had on patients handled in a primary healthcare setting. Results: We found a heart rhythm disorder in 8.6% of patients before the COVID-19 pandemic and in 15.2–17.9% of patients during the COVID-19 pandemic, where the difference was statistically significant (p = 0.002). During the COVID-19 pandemic, we found a heart rhythm disorder in almost 50% of patients that had tested positive for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 virus) more than one month ago. After the vaccinations started, we also found a heart rhythm disorder in almost 50% of non-vaccinated patients. Conclusions: Using a telemedical approach or remote consultation is a useful method, at the primary healthcare level, for diagnosing and treating patients with palpitations during times of lockdown.

Research on Digital Technology Use in Cardiology: Bibliometric Analysis

Background

Digital technology uses in cardiology have become a popular research focus in recent years. However, there has been no published bibliometric report that analyzed the corresponding academic literature in order to derive key publishing trends and characteristics of this scientific area.

Objective

We used a bibliometric approach to identify and analyze the academic literature on digital technology uses in cardiology, and to unveil popular research topics, key authors, institutions, countries, and journals. We further captured the cardiovascular conditions and diagnostic tools most commonly investigated within this field.

Methods

The Web of Science electronic database was queried to identify relevant papers on digital technology uses in cardiology. Publication and citation data were acquired directly from the database. Complete bibliographic data were exported to VOSviewer, a dedicated bibliometric software package, and related to the semantic content of titles, abstracts, and keywords. A term map was constructed for findings visualization.

Results

The analysis was based on data from 12,529 papers. Of the top 5 most productive institutions, 4 were based in the United States. The United States was the most productive country (4224/12,529, 33.7%), followed by United Kingdom (1136/12,529, 9.1%), Germany (1067/12,529, 8.5%), China (682/12,529, 5.4%), and Italy (622/12,529, 5.0%). Cardiovascular diseases that had been frequently investigated included hypertension (152/12,529, 1.2%), atrial fibrillation (122/12,529, 1.0%), atherosclerosis (116/12,529, 0.9%), heart failure (106/12,529, 0.8%), and arterial stiffness (80/12,529, 0.6%). Recurring modalities were electrocardiography (170/12,529, 1.4%), angiography (127/12,529, 1.0%), echocardiography (127/12,529, 1.0%), digital subtraction angiography (111/12,529, 0.9%), and photoplethysmography (80/12,529, 0.6%). For a literature subset on smartphone apps and wearable devices, the Journal of Medical Internet Research (20/632, 3.2%) and other JMIR portfolio journals (51/632, 8.0%) were the major publishing venues.

Conclusions

Digital technology uses in cardiology target physicians, patients, and the general public. Their functions range from assisting diagnosis, recording cardiovascular parameters, and patient education, to teaching laypersons about cardiopulmonary resuscitation. This field already has had a great impact in health care, and we anticipate continued growth.

Telecardiology in Rural Practice: Global Trends

The management of cardiovascular diseases in rural areas is plagued by the limited access of rural residents to medical facilities and specialists. The development of telecardiology using information and communication technology may overcome such limitation. To shed light on the global trend of telecardiology, we summarized the available literature on rural telecardiology. Using PubMed databases, we conducted a literature review of articles published from January 2010 to December 2020. The contents and focus of each paper were then classified. Our search yielded nineteen original papers from various countries: nine in Asia, seven in Europe, two in North America, and one in Africa. The papers were divided into classified fields as follows: seven in tele-consultation, four in the telemedical system, four in the monitoring system, two in prehospital triage, and two in tele-training. Six of the seven tele-consultation papers reported the consultation from rural doctors to urban specialists. More reports of tele-consultations might be a characteristic of telecardiology specific to rural practice. Further work is necessary to clarify the improvement of cardiovascular outcomes for rural residents.

The Telecardiology Revolution: From Emergency Management to Daily Clinical Practice

AIMS

Telecardiology is one of the most widespread applications of telemedicine. We aimed to report the design and development of a telecardiology system in the sanitary district of Cosenza, one of the largest in Italy, with a complex orography, and healthcare reorganization needs, for the management of the emergency network and daily clinical practice.

METHODS

Our telecardiology network connects 8 hospitals, 9 first aid centers, 20 local 118-EMS stations, 1 helicopter station, 8 hospital emergency departments, 59 hospital departments, and 3 catheterization laboratories. All data are centralized on a dedicated server, accessible from any location for real-time assessment. The quality, source, and timing of the electrocardiograms transmitted were evaluated.

RESULTS

From October 2015 to December 2019, a total of 389,970 ECGs were transmitted. The quality of ECGs was optimal in 52%, acceptable in 42%, and poor in 6% of the cases. The number of poor-quality ECGs was only 3% in the last 2 years. Out of the total, 145,097 (37.2%) were transmitted from the emergency departments and 5318 (1.4%) from the 118-EMS. Of interest, a sizable part of the ECG was related to routine clinical practice, comprising 110,556 (28.3%) from the cardiology department and 79,256 (20.3%) from other noncardiovascular departments. Finally, the average reporting time was significantly decreased compared to reporting times without a telecardiology system (5-10 vs. 45-90 min).

CONCLUSION

Our telecardiology system provides efficient cardiology assistance for all types, settings, and phases of cardiovascular diseases.

Telemedicine Applications in the Era of COVID-19: Telesurgery Issues

Telemedicine allows for the effective delivery of health care to patients at a distance through the application of information technology to the field of medicine. This is optimal during the COVID-19 pandemic to reduce interpersonal contact to mitigate contagion. Among the possible Telemedicine applications, there is Telesurgery, which involves more and more surgical specialties thanks to the numerous benefits in quality and cost containment. In the growing field of Telesurgery, its technical and legal implications must be considered. In this study, a traditional review of the scientific literature was carried out to identify the most relevant issues of interest in Telesurgery. The problematic legal aspects identified are mainly related to the difference in legislation between different geographical areas, which is critical in the case of malpractice. In addition, there is the possibility of a malicious hacker attack on the transmitted data stream either to steal sensitive data or to harm the patient. Finally, there are inherent difficulties with the technology used, such as latency issues in data transmission. All these critical issues are currently not adequately addressed by current legislation. Therefore, one can only hope for a legislative action to allow Telesurgery to be used safely.

Telecardiology interventions for patients with cardiovascular Disease: A systematic review on characteristics and effects

INTRODUCTION

The prevalence and mortality of cardiovascular diseases are high worldwide. Telecardiology can be used to diagnose and treat these diseases. This paper aimed to review the effectiveness (positive and negative) of implemented telecardiology services in terms of clinical, economic, and patient-reported aspects.

METHODS

A comprehensive search was conducted in Medline (through PubMed), Scopus, ISI web of science, and IEEE Xplore databases from inception to April 7, 2021. the studies that examined the effectiveness of telecardiology interventions were included.

RESULTS

Fifty studies were included in this systematic review. Most investigations (22%) were conducted in the US. In 22% of studies, telecardiology intervention was used for patients with heart failure. Telecardiology has been used in most studies for tele-monitoring (n = 21, 42%) and tele-consultation (n = 17, 34%) and in 29 studies (58%), was applied for ECG transmission. The highest rate of effects reported by studies was clinical. Thirty-five studies (70%) reported the clinical effects; twenty-one studies reported the positive effects for the economic category, and fifteen studies reported the positive effect for patient-reported class. The most positive clinical effects of telecardiology were early diagnosis, early treatment, and mortality reduction. The most positive effect of the economic class was the reduction of health care costs. The most effects of the patient-reported category were improving the patient's quality of life and patient satisfaction.

CONCLUSION

Telecardiology can help early diagnosis and treatment of cardiovascular diseases. It also has great potential in reducing health care costs and increasing quality of life and patient satisfaction.

Virtual visits in cardiovascular disease: a rapid review of the evidence

Given the high prevalence of cardiovascular disease (CVD) in Canada and globally, as well as the staggering cost to human life and health systems, there is an urgent need to understand the successful applications of telemedicine in cardiovascular medicine. While telemedicine in cardiology is well documented, reports on virtual care in the form of synchronous, real-time communication between healthcare providers and patients are limited. As a result of the immediate suspension of ambulatory services for cardiology in Alberta, Canada, due to the Coronavirus Disease 2019 pandemic, we undertook a rapid review on the impact of non-virtual visits in cardiovascular ambulatory settings on patients’ healthcare utilization and mortality. Evidence from 12 randomized control trials and 7 systematic reviews was included in the rapid review, with the majority of papers (n = 15) focusing on telemedicine in heart failure. Based on our appraisal of evidence from the last 5 years, virtual visits are non-inferior, or more effective, in reducing hospitalizations and visits to emergency departments in patients with CVD compared to traditional standard in-clinic/ambulatory care. The evidence for a superior effect of virtual visits in reducing mortality was not supported in this review. While telemedicine is an appropriate tool for CVD follow-up care, more research into the efficacy of different components of telemedicine and virtual visits is required.

Association of Financial Factors and Telemedicine Adoption for Heart Attack and Stroke Care Among Rural and Urban Hospitals: A Longitudinal Study

Introduction: To examine trends in telemedicine adoption for stroke and cardiac care among U.S. hospitals, specifically associations between hospital financial indicators and adoption of these telemedicine services. Methods: This is a retrospective analysis of data from the Health Information Management and System Society Dorenfest Database and Healthcare Cost Report Information System from 2012 to 2017. We used a pooled ordinary least squares model and reported results as average marginal effects (AMEs). Results: The number of hospitals with stroke or cardiac telemedicine services in urban and rural areas increased through our study period from 153 (7.30%) to 407 (19.42%) and from 127 (6.31%) to 331 (16.45%), respectively. In rural hospitals, being a for-profit hospital (AME = -10.49, 95% confidence interval [CI] = -14.01 to -6.98) and having an increase in Medicare inpatient mix (AME = -0.31, 95% CI = -0.42 to -0.20) were associated with the probability of telemedicine adoption for heart attack and stroke care. A couple of nonfinancial variables included in the model also were associated with adoption, specifically having one more licensed bed (AME = -0.02, 95% CI = -0.04 to -0.00) and higher number of emergency department visits (AME = 5.64, 95% CI = 2.83 to 7.20). In urban hospitals, being a for-profit hospital (AME = -8.94, 95% CI = -11.76 to -6.11) and having a higher total margin (AME = 0.17, 95% CI = 0.08 to 0.26) were associated with the probability of telemedicine adoption for heart attack and stroke care. Two nonfinancial variables also were statistically significant: having one more licensed bed (AME = 0.01, 95% CI = 0.041 to 0.02) and being closer to another telemedicine hospital (AME = 0.81, 95% CI = -1.62 to 0.01). Discussions: Telemedicine adoption rate for cardiac and stroke care has increased significantly in recent years. Financial status may be a bigger driver of adoption for urban hospitals than rural hospitals.

Health Information Technology Use Among Persons With Self-reported Atherosclerotic Cardiovascular Disease: Analysis of the 2011-2018 National Health Interview Survey

BACKGROUND

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality in the United States. Health information technologies (HITs) have recently emerged as a viable intervention to mitigate the burden of ASCVD. Approximately 60% of US adults report searching the internet for health information; however, previous research has not examined the prevalence of general technology or HIT use among adults with and without ASCVD. In addition, social determinants in HIT use among adults with ASCVD are not well understood.

OBJECTIVE

The aim of this study was to evaluate the prevalence and social determinants of HIT use among US adults with versus without self-reported ASCVD.

METHODS

We pooled cross-sectional data from the 2011-2018 National Health Interview Survey (NHIS) to examine the general technology and HIT use among adults aged ≥18 years with and without self-reported ASCVD (coronary heart disease, stroke, or both). General technology use was defined as mobile phone ownership, internet use, and computer use. HIT use was defined as looking up health information on the internet, filling a web-based prescription, scheduling a medical appointment on the internet, communicating with a health care provider by email, or using web-based group chats to learn about health topics. We evaluated sociodemographic differences in HIT use among respondents by using Poisson regression. Analyses were weighted according to NHIS standards.

RESULTS

A total sample of 256,117 individuals were included, of which 2194 (0.9%) reported prior ASCVD. Among adults with prior ASCVD, the mean age was 70.6 (SD 11.5) years, and 47.4% (1048/2194) of the adults were females. General technology use differed between participants with and without prior ASCVD, with 36.0% (614/1826) and 76.2% (157,642/213,816) indicating internet usage and 24.6% (374/1575) and 60.7% (107,742/184,557) indicating using a computer every day, respectively. Similarly, adults with ASCVD were less likely to use HIT than those without ASCVD (515/2194, 25.1% vs 123,966/253,923, 51.0%; P<.001). Among adults with prior ASCVD, social determinants that were associated with HIT use included younger age, higher education, higher income, being employed, and being married.

CONCLUSIONS

HIT use was low among adults with a history of ASCVD, which may represent a barrier to delivering care via emerging HIT. Given the associations with social determinants such as income, education, and employment, targeted strategies and policies are needed to eliminate barriers to impact HIT usage.

Impact of 2020 SARS-CoV-2 outbreak on telemedicine management of cardiovascular disease in Italy

The Covid-19 pandemic affected large part of Italy since February 2020; we, therefore, aimed to assess the impact of 2020 SARS-CoV-2 outbreak on telemedicine management of cardiovascular disease (CVD) in Italy. We analyzed data from three telemedicine dispatch centers, one located in Genoa, serving private clients (pharmacies, general practitioners), one in Brescia, serving pharmacies, and one in Bari, serving regional public STEMI network and emergency medical service in Apulia (4 million inhabitants). Demographic data and principal electrocardiogram diagnosis were collected and analyzed. Records from the time interval March 1, 2020 and April 1, 2020 were compared with the corresponding period in 2019. The comparative analysis of data shows a 54% reduction of telemedicine electrocardiogram transmission in Genoa telemedicine center (from 364 to 166), 68% in Brescia (from 5.745 to 1.905), 24% in Bari (from 15.825 to 11.716); relative reduction according to electrocardiogram diagnosis was 38% for acute coronary syndrome, 40% for other acute CVD in Genoa center, 24% for acute coronary syndrome, and 38% for other acute CVD in Bari. Male/female ratio remained substantially unchanged. A dramatic reduction of telemedicine access for CVD was observed during Covid-19 outbreak in March 2020 in Italy. The reduction was substantially consistent for all electrocardiogram findings, ACS, other acute CVD and normal.

The Benefits of Telemedicine in Personalized Prevention of Cardiovascular Diseases (CVD): A Systematic Review

INTRODUCTION

Adverse effects on personalized care and outcomes of cardiovascular diseases (CVD) could occur if health systems do not work in an efficient manner. The pandemic caused by COVID-19 has opened new perspectives for the execution and advancement of cardiovascular tests through telemedicine platforms.

OBJECTIVE

This study aimed to analyze the usefulness of telemedical systems for providing personal care in the prevention of CVD.

METHODS

A systematic review analysis was conducted on the literature available from libraries such as PubMed (Medline), Scopus (Embase), and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Data available in the last 10 years (2011-2020) were also examined by PRISMA guidelines. The selected studies were divided into two categories: (1) benefits of telemedicine in CVD prevention, and (2) recent progress in telemedical services for personalized care of CVD.

RESULTS

The literature search produced 587 documents, and 19 articles were considered in this review. Results highlighted that the timely delivery of preventive care for CVD which can be implemented virtually can benefit and modify morbidity and mortality. This could also reduce the pressure on hospitals by decreasing acute CVD occurrence among the general population. The use of these technologies can also help to reduce access to hospitals and other medical devices when not necessary.

CONCLUSIONS

Telemedicine platforms can be used for regular checkups for CVD and contribute to preventing the occurrence of acute events and more in general the progression of CVD.

COVID-19 and STEMI: The role of telecardiology in the management of STEMI diagnosis during COVID 19 pandemic

BACKGROUND

Telecardiology has the advantage of reducing patient's access time to the hemodynamics units. Data from literature show a reduction in ST-elevation myocardial infarction (STEMI) during COVID-19 pandemic. However, there is a low number of studies on the impact of telecardiology during the pandemic.

METHODS

Our telecardiology system is composed of a Hub-and-Spoke network of hospitals and ambulances that ensures a rapid exchange of information allowing STEMI patients to be treated in the shortest time possible. We compared data from electrocardiograms (ECGs) transmissions and STEMI diagnosis collected between February and April 2020 with the data from the same period of 2019.

RESULTS

Despite a significant reduction of ECGs transmissions from the telecardiology network was observed, the number of diagnosed STEMI during 2020 was stable and did not show any significant difference compared to 2019. The total number of STEMI diagnosis in the months under examination during 2019 were 47 out of 7463 ECGs (0.63%), while in 2020 were 48 out of 5797 ECGs (0.83%).

CONCLUSIONS

The efficiency of our telecardiology system along with the low spread of the infection in our region contributed to maintaining the number of STEMI diagnosis and patient's care in line with the past even during the pandemic.

Medical Legal Aspects of Telemedicine in Italy: Application Fields, Professional Liability and Focus on Care Services During the COVID-19 Health Emergency

Telemedicine services can be classified into the macro-categories of specialist Telemedicine, Tele-health and Tele-assistance. From a regulatory perspective, in Italy, the first provision dedicated to the implementation of Telemedicine services is represented by the Agreement between the Government and the Regions on the document bearing “Telemedicine—National guidelines,” approved by the General Assembly of the Superior Health Council in the session of 10th July 2012 and by the State Regions Conference in the session of 20th February 2014. Scientifically, several studies in the literature state that information and communication technologies have great potential to reduce the costs of health care services in terms of planning and making appropriate decisions that provide timely tools to patients. Another clear benefit is the equity of access to health care. The evolution of telemedicine poses a series of legal problems ranging from the profiles on the subject of authorization and accreditation to those concerning the protection of patient confidentiality, the definition and solution of which, in the absence of specific regulatory provisions, is mainly left to the assessment of compatibility of the practices adopted so far, with the general regulatory framework. In terms of professional liability, it is necessary to first clarify that the telemedicine service is comparable to any diagnostic-therapeutic health service considering that the telemedicine service does not replace the traditional health service, but integrates the latter to improve its effectiveness, efficiency and appropriateness.

Telemedicine for Pre-Employment Medical Examinations and Follow-Up Visits on Board Ships: A Narrative Review on the Feasibility

BACKGROUND

Telemedicine has already been applied to various medical specialties for diagnosis, treatment, and follow-up visits for the general population. Telemedicine has also proven effective by providing advice, diagnosis, and treatment to seafarers during emergency medical events onboard ships. However, it has not yet been applied for pre-employment medical examinations and follow-up visits on board ships.

OBJECTIVE

This review aimed to assess the possibility of using telemedicine during periodic visits between one pre-employment medical examination and others on board ships, and to recommend necessary medical examination tests with screening intervals for seafarers.

METHODS

Various databases including PubMed, EMBASE, Scopus, CINAHL, and Cochrane Library were explored using different keywords, titles, and abstracts. Studies published between 1999 and 2019, in English, in peer-reviewed journal articles, and that are conference proceedings were considered. Finally, the studies included in this review were chosen on the basis of the eligibility criteria.

RESULTS

Out of a total of 168 studies, 85 studies were kept for further analysis after removing the duplicates. A further independent screening based on the inclusion and exclusion criteria resulted in the withdrawal of 51 studies that were not further considered for our analysis. Finally, 32 studies were left, which were critically reviewed. Out of 32 accepted studies, 10 studies demonstrated the effectiveness of the electrocardiogram (ECG) in monitoring and managing remote patients with heart failure, early diagnosis, and postoperative screening. In 15 studies, telespirometry was found to be effective in diagnosing and ruling out diseases, detecting lung abnormalities, and managing patients with chronic obstructive pulmonary disease (COPD) and asthma. Seven studies reported that telenephrology was effective, precise, accurate, and usable by non-medical personnel and that it reduced sample analysis times and procedures in laboratories.

CONCLUSION

using new technologies such as high-speed internet, video conferencing, and digital examination, personnel are able to make the necessary tests and perform virtual medical examination on board ships with necessary training.

An IoT and Fog Computing-Based Monitoring System for Cardiovascular Patients with Automatic ECG Classification Using Deep Neural Networks

Telemedicine and all types of monitoring systems have proven to be a useful and low-cost tool with a high level of applicability in cardiology. The objective of this work is to present an IoT-based monitoring system for cardiovascular patients. The system sends the ECG signal to a Fog layer service by using the LoRa communication protocol. Also, it includes an AI algorithm based on deep learning for the detection of Atrial Fibrillation and other heart rhythms. The automatic detection of arrhythmias can be complementary to the diagnosis made by the physician, achieving a better clinical vision that improves therapeutic decision making. The performance of the proposed system is evaluated on a dataset of 8.528 short single-lead ECG records using two merge MobileNet networks that classify data with an accuracy of 90% for atrial fibrillation.

Prehospital tele-electrocardiographic triage improves the management of acute coronary syndrome in rural populations: A systematic review and meta-analysis

INTRODUCTION

Acute coronary syndrome (ACS) patients residing in rural areas are predisposed to higher risk of poor outcomes due to substantial delays in disease management, emphasising the importance of emerging telecardiology technologies in delivering emergency services in such settings. This meta-analysis aimed to investigate the impacts of prehospital telecardiology strategies on the clinical outcomes of rural ACS patients.

METHODS

A literature search was performed of articles published up to April 2020 through six databases. Included studies were assessed for bias risk using the ROBINS-I tool, and a random-effects model was utilised to estimate effect sizes. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

RESULTS

Twelve studies with a total of 3989 patients were included in this review. Prehospital telecardiology in the form of tele-electrocardiography (tele-ECG) enabled prompt diagnosis and triage, resulting in a decreased door-to-balloon (DTB) time (mean difference = -25.53 minutes, 95% confidence interval (CI) -36.08 to -14.97 minutes; I² = 98%), as well as lower in-hospital mortality (odds ratio (OR) = 0.57, 95% CI 0.36-0.92) and long-term mortality (OR = 0.52, 95% CI 0.39-0.69) rates, both with negligible heterogeneity (I² = 0%). GRADE assessment yielded very low to moderate certainty of evidence.Conclusion Prehospital tele-ECG appeared to be an effective and worthwhile approach in the management of rural ACS patients, as shown by moderate quality evidence on lower long-term mortality. Given the uncertainties of the evidence quality on DTB time and in-hospital mortality, future studies with a higher quality of evidence are required to confirm our findings.

The Future of Cardiac Ultrasound in the Neonatal Intensive Care Unit

Cardiac ultrasound is increasingly used to guide hemodynamic decision making in the neonatal intensive care unit (NICU). This article focuses on likely future progress in training, accreditation, digital connectivity, miniaturization, and modality development. Many documents have been published internationally to guide cardiac ultrasound training, accreditation, and implementation in the NICU, but challenges remain in providing assessments of hemodynamic status without risking missed structural diagnoses. Advances in simulation training and digital connectivity provide an opportunity to standardize approaches across institutions and continents. Development of machine learning and ultrasound modalities in turn provide huge scope for improving robustness and completeness of assessment.

[Experience of tele-expertise in cardiology in Pays de la Loire]

INTRODUCTION

General practitioners regularly need specialized advice for therapeutic adaptation, ECG interpretation or to facilitate referral to the local cardiologist. Tele-expertise could amplify these possibilities of coordination between professionals. An experiment in tele-expertise in cardiology was carried out by the URML in Pays de la Loire between 2016 and 2017. This experiment allowed GPs to seek the advice of a liberal cardiologist via a link card. The cardiologist received the card, accompanied by the ECG and responded within 48 hours.

OBJECTIVES

The objective was to study the acceptability of the experiment and to study the impact on the coordination of health care professionals and on delays.

METHOD

This evaluation required a mixed methodology with a before/after the experiment survey, semi-directive interviews with GP and cardiologists, ad hoc data collection and data from national health insurance claim database.

RESULTS

In 15 months of experimentation, 22% of GPs and 52% of liberal cardiologists of the territory participated. 959 reviews were requested by the GPs or 74 cards per month. The cardiologists were solicited 2.3 times a month. The cardiologist rated the ECG abnormal or doubtful for 31.9% of exams. An appointment was scheduled on average within 24 days. Few difficulties in using the service have been reported by users.

DISCUSSION

The results show that tele-expertise without any complex computer tools to work, helps to improve the organization of the gradation of the response of the specialized offer, to improve the confidence of GPs in their own ECG analysis. It constitutes a full-scale observatory of the implementation of tele-expertise in cardiology, upstream of its generalization announced for 2020 in France.

Call to Action: Rural Health: A Presidential Advisory From the American Heart Association and American Stroke Association

Understanding and addressing the unique health needs of people residing in rural America is critical to the American Heart Association's pursuit of a world with longer, healthier lives. Improving the health of rural populations is consistent with the American Heart Association's commitment to health equity and its focus on social determinants of health to reduce and ideally to eliminate health disparities. This presidential advisory serves as a call to action for the American Heart Association and other stakeholders to make rural populations a priority in programming, research, and policy. This advisory first summarizes existing data on rural populations, communities, and health outcomes; explores 3 major groups of factors underlying urban-rural disparities in health outcomes, including individual factors, social determinants of health, and health delivery system factors; and then proposes a set of solutions spanning health system innovation, policy, and research aimed at improving rural health.