Telecardiology in Pediatric Cardiac Care

Telecardiology:
The future of pediatric cardiac care

CATHERINE L. WEBB, MD

aFall 1999

Congenital heart disease is the leading cause of infant mortality in the United States, representing 36% of all infant deaths due to birth defects.¹ Because infants with congenital heart disease are often critically ill in the newborn period, they require emergent access to highly specialized cardiac diagnosis and management at a tertiary care center. Traditional methods of neonatal cardiac care delivery are, in many cases, time consuming, resulting in delayed diagnosis in these critically ill infants. Children’s Memorial Hospital has been a leader in the development of an interactive videoconferencing technique, which allows transmission of echocardiograms in real time from the patient’s bedside at an outreach hospital site. This has resulted in a significant decrease in time to diagnosis, an improved ability to triage patients for transport and improved cost efficiency, without compromise of diagnostic accuracy. This article describes the new telecardiology technology as compared to traditional methods of neonatal cardiac care and outlines ongoing research efforts in this area.

TRADITIONAL INFANT CARDIAC CARE

Although many hospitals maintain full time pediatric cardiologists and supply technology and equipment needs, this strategy requires significant institutional financial commitment. Since the incidence of congenital heart disease ranges from 6 to 8/1000 newborns, many hospitals do not have enough volume to justify full pediatric cardiology services. Therefore these hospitals have traditionally contracted for pediatric cardiology consultative services with a tertiary care institution.

Traditional cardiac care delivery to date has involved combinations of the following services: telephone consultation between the referring pediatrician or neonatologist and the pediatric cardiologist, which may result in transport of an infant to a tertiary care center for an echocardiogram; sonographers employed by outreach sites who are generally trained in adult cardiac sonography only, perform the echocardiogram and the videotape is then delivered to a tertiary care center for interpretation; a sonographer employed by a pediatric tertiary care center and who is trained in pediatric echocardiography travels to an outreach site on request, performs an echocardiogram and returns with the videotape for interpretation; or a pediatric cardiologist may need to travel to the outreach site to consult and perform an echocardiogram. Thus, traditional cardiac echocardiographic services are delivered in a personnel and time-intensive manner.

Traditional care may result in a delay in diagnosis either because videotapes sent for review are delayed (or in some cases even lost), or transit times for transport or tertiary care pediatric cardiologists and sonographers are high. Since intervention and appropriate therapy must await diagnosis of heart disease by a pediatric cardiologist, a neonate with suspected congenital heart disease is at risk for serious adverse medical outcomes including shock, acidosis and possibly death.

The neonate may also be exposed to the additional risk of a potentially unnecessary transport. Importantly, parents experience significant anxiety related to delayed diagnosis as well as separation from their newborn child if a transport to a tertiary care hospital occurs before a diagnosis of congenital heart disease is made. Finally, compared to telemedicine, the cost of traditional consultative arrangements with tertiary care hospitals is higher, both for infants and for outreach hospitals, particularly if a transport occurs which may have been unnecessary in retrospect.

WHAT IS TELEMEDICINE?

Telemedicine is essentially a form of videoconferencing. Recent advances in telecommunications have made delivery of sophisticated cardiac diagnostic care to distant outreach sites a reality. In 1959, a microwave link was used for videoconferencing between two psychiatric centers 112 miles apart.² More recently, cardiologists have employed telephone lines and analog modems to transmit compressed, still-frame echocardiographic images or selected cine-loops.^3,4

By the mid-1980s when the proliferation of digital communication technologies occurred, investigators used fiberoptics, cable, satellites and microwave transmitters to transmit echocardiograms in real time.⁵ Transtelephonic transmission of real time echocardiographic images utilizing an Integrated Services Digital Network (ISDN) telephone line is currently being employed by an increasing number of medical centers.^6,7 This technology is similar to standard telephone lines in that both voice and data are transmitted over the same twisted copper wire. Importantly, a number of centers, using various telemedicine transmission methods, have all recently demonstrated that accuracy of neonatal cardiac diagnosis using telemedicine is comparable to accuracy achieved when the diagnosis is made by traditional methods of infant cardiac care delivery.⁸

In addition, Berdusis et al.⁹ have demonstrated that a telemedicine link to a tertiary care center results in significantly decreased costs for remote institutions who experience a low volume of suspected neonatal congenital heart disease. Telecardiology also demonstrated no increase in direct costs to the tertiary care center when compared to traditional delivery of care.9 Importantly, telecardiology has recently demonstrated average savings of approximately $5,000 per patient when unnecessary transport to a tertiary care center was eliminated.¹⁰

Telecardiology includes not only interpretation of transmitted echocardiograms, but electrocardiograms and Holter monitors as well. Videoconferencing interactions with pediatricians, neonatologists and parents occur regularly with the pediatric cardiology staff at the tertiary care institution. Additional applications may include transmission of X-rays, CT scans, MRI scans as well as real time viewing of ongoing cardiac catheterizations or surgical procedures.

PAST AND CURRENT TELECARDIOLOGY SERVICES AT CHILDREN’S MEMORIAL HOSPITAL

Children’s Memorial Hospital began telecardiology services in 1993 using one ISDN line (transmission rate= 128 kbps) linked to Northwest Community Hospital in Arlington Heights, Illinois. The service was upgraded shortly thereafter to include three ISDN lines, which results in a transmission rate of 384 kbps.

Currently, Children’s Memorial Hospital uses these three ISDN lines to link with five outreach hospitals in the Chicago metropolitan area. These Illinois outreach hospitals are: Evanston Hospital, Evanston; Highland Park Hospital, Highland Park; Ingalls Hospital, Harvey; Northwest Community Hospital, Arlington Heights; and Silver Cross Hospital, Joliet. Additional sites will soon be included in this network.

FIGURE 1. The volume of transmitted echocardiograms from outreach hospitals to Children’s Memorial Hospital has increased significantly since this telecardiology service was instituted in 1993.

Figure 1 shows the steady increase in numbers of echocardiograms transmitted since inception of this service. The program has grown from 20 to 30 transmissions per year in 1993 to more than 275 transmissions done during 1998. This increase reflects not only the increasing number of outreach sites participating in the telecardiology program, but also the increasing enthusiasm for the use of this technology.

HOW DOES TELECARDIOLOGY AT CHILDREN’S WORK?

The most important concept to understand about telecardiology at Children’s Memorial Hospital (and most other pediatric telecardiology sites currently in use in the United States) is that transmission of echocardiograms from the outreach site to the tertiary care site occurs in real time. This means that there is ongoing interaction between the sonographer at the patient’s bedside at the outreach site and the pediatric cardiology staff at Children’s Memorial Hospital throughout the performance of the echocardiogram. The ISDN connection is plugged directly into the ultrasound machine at the outreach hospital nursery.

FIGURE 2. Dr. Catherine L. Webb supervises an echocardiogram being transmitted in real time from Evanston Hospital. Areas of concern which she identifies can be more carefully scrutinized immediately by directing the sonographer to make changes in transducer position or echocardiographic views.

A mobile computer station with appropriate hardware and software for videoconferencing is also hooked up to the ultrasound machine, and the sonographer is able to switch between a window that shows the screen on the ultrasound machine (Figure 2) and a window which allows the pediatric cardiologist to view the nursery environment and the baby (Figure 3).

FIGURE 3. The ultrasonographer at Evanston Hospital is doing an echocardiogram on the baby in the incubator under the direction of Dr. Catherine L. Webb. The sonographer can switch between the two screens shown on the ultrasound machine window. The small screen on the left allows her to visualize the ultrasound images. The full screen (right) allows her to visualize Dr. Webb. Either screen can be enlarged to cover the entire screen of the ultrasound machine.

Using this second window, the cardiologist can also directly interact with the referring pediatrician or neonatologist and the parents of the baby as requested. As the sonographer is doing the echocardiogram, the pediatric cardiology staff can help guide the study by asking for changes in transducer position or ultrasound machine settings. In addition, echocardiographic views seldom used in adult patients, but necessary for diagnosis of congenital heart disease, can be obtained by sonographers with little pediatric experience with a bit of simple, ongoing instruction and guidance from the pediatric cardiology team. This ability to interactively supervise the echocardiogram results in diagnostically accurate studies that can be completed in significantly less time than needed in the traditional method of infant cardiac care delivery. Appropriate medical intervention can then be started immediately.

COST OF TELECARDIOLOGY AT CHILDREN’S MEMORIAL

The ISDN technology is one of the most economical methods used for telemedicine transmissions. Based on our experience with the five outreach centers currently up and running, the cost of initial installation of the three ISDN lines has varied from $2,000 to approximately $25,000 and has been dependent on the complexity of the installation issues.

There is a nominal monthly charge per ISDN line (currently $50/line in the Chicago area) plus a usage charge (currently 40 cents/minute). A desktop PC system with appropriate hardware and software for videoconferencing can be purchased for less than $10,000. The ISDN system is generally reliable and depends on the local telephone company reliability. Installation of a T1 line, fiberoptic cable, or a satellite link system currently require much more significant initial financial outlays, often an order of magnitude greater than installation of the ISDN lines. Currently, T1 and fiberoptic lines are less available than ISDN lines in the Chicago area and have other technical and financial considerations that make them less attractive at this time. Reliable satellite transmission is dependent on weather conditions and on military constraints in some areas.

Charges for the transmitted echocardiogram are negotiated individually with each outreach site. Some sites charge the patient a hospital charge for the echocardiogram, and Children’s Memorial Hospital then bills the patient separately for the professional interpretation fee (unbundled charges). Other sites prefer to pay a flat yearly fee to Children’s Memorial Hospital for telemedicine services, and then they bill the patient directly for both the hospital charge and the professional component (bundled charges).

ADVANTAGES OF TELEMEDICINE FOR MEDICAL EDUCATION

In addition to the obvious advantages of telecardiology noted above, telemedicine can make a significant impact on educating physicians on the care of patients with known or suspected heart disease. Children’s Memorial Hospital currently has an international outreach link with Aghia Sophia Children’s Hospital in Athens, Greece. This site is used primarily for consultation with the physicians in Athens regarding options for children with complicated congenital defects requiring surgery. Surgeons in Greece are able to watch congenital heart surgery in progress at Children’s Memorial Hospital, and surgeons in Chicago are able to watch surgery in Athens. Children’s Memorial Hospital has also used telemedicine for teaching conferences in Tel-Aviv, Israel, and Moscow, Russia. Children’s Memorial is also currently in the process of setting up teleconferencing links with outreach hospitals in the Chicago area in order to transmit weekly Grand Rounds.

THE FUTURE OF TELECARDIOLOGY

Telemedicine may improve both medical and financial outcomes in the delivery of emergent pediatric cardiac care for neonates with suspected congenital heart disease. In the current era of enforced cost economy in the health care system, outcomes research is necessary to demonstrate the value of a new technology in shortening time to diagnosis and improving cost efficiency.

A number of recent descriptive studies cited above have demonstrated this in a few patients at individual centers. However, because the sample sizes are small so far, we have been unable to test for statistically significant differences in outcome between patients diagnosed by traditional methods of cardiac care compared to those diagnosed by telecardiology. Clearly, a multicenter study needs to be done in order to conclusively document the benefits of telecardiology.

Children’s Memorial Hospital has taken the lead in this endeavor. Dr. Catherine L. Webb, associate professor of pediatrics and director of telecardiology at Children’s Memorial Hospital along with Dr. David J. Sahn, professor of pediatrics, obstetrics and gynecology, and radiology at Oregon Health Sciences University in Portland, Oregon, are co-principal investigators in a multicenter pediatric telemedicine trial that began July 1, 1999, and will run through December 31, 2000. This study has been funded both by the American Society of Echocardiography and by a local Chicago philanthropic organization.

Drs. Webb and Sahn, along with co-investigator, Kaliope Berdusis, RDMS, and consultant, Jim Grigsby, PhD, will lead 25 pediatric cardiology centers throughout the United States (Table 1) in an 18-month investigation comparing medical and financial outcomes of telecardiology and traditional methods of cardiac care delivery for neonates with suspected congenital heart disease. Medical outcomes to be studied include differences between patients diagnosed by telecardiology vs. traditional methods of cardiac care such as: time to diagnosis, diagnostic accuracy, shock, acidosis, death, parental anxiety due to longer time to diagnosis, and parental separation from the child.

TABLE 1 Collaborators and Participating Institutions. These 25 pediatric cardiology centers throughout the United States are participating in the multicenter telecardiology trial entitled “Medical and Financial Outcomes Using Telemedicine for Diagnosis of Neonatal Congenital Heart Disease.”
Ernerio T. Alboliras, MD	Rush-Presbyterian-St. Luke’s Med. Ctr., Chicago
Nancy Ayres, MD	Texas Children’s Hospital, Houston
A. Resai Bengur, MD	Duke Children’s Hospital, Durham
Andrew S. Bensky, MD	Wake Forest Baptist Med. Ctr., Winston-Salem
Michael Brook, MD	Moffett-Long Hospital, San Francisco
Fredrick K. Emge, MD	Children’s Hospital of New Jersey, Newark
Donald K. Hagler, MD	Mayo Clinic, Rochester
Patrick W. O’Leary, MD	Mayo Clinic, Rochester
Richard A. Humes, MD	Children’s Hospital of Michigan, Detroit
Ann K. Kavanaugh-McHugh, MD	Vanderbilt University Medical Ctr., Nashville, TN
Achi Ludomirsky, MD	C. S. Mott Children’s Hospital, Ann Arbor, MI
Gerald R. Marx, MD	Boston Children’s Hospital, Boston
David J. Miller, MD	Columbia Presbyterian/St. Luke’s Med. Ctr., Denver
Sang C. Park, MD	Children’s Hospital, Pittsburgh
John C. Ring, MD	LeBonheur Children’s Med. Ctr., Memphis
Nancy Ross-Ascuitto, MD	Tulane Medical Center, New Orleans
Craig Sable, MD	Children’s National Medical Ctr., Washington, D.C.
David J. Sahn, MD	OHSU/Doembecher Children’s Hospital, Portland
Elizabeth Shaffer, MD	The Children’s Hospital, Denver
Frank C. Smith, MD	SUNY, Syracuse, NY
Theresa Pryor Roca, MD	Oschner Clinic, New Orleans
Walter L. Sobczyk, MD	Kosair Children’s Hospital, Louisville
Catherine L. Webb, MD	Children’s Memorial Hospital, Chicago
L. Timothy Wolfe, MD	Janet Weiss Children’s Hospital, Pittsburgh
Pierre C. Wong, MD	Children’s Hospital, Los Angeles

Financial outcomes to be studied include cost savings to patients due to improved ability to triage patients for transport after telemedicine diagnosis, cost savings to outreach institutions by decreasing the cost of cardiology consultations, and the ability of outreach institutions to recoup some of the charge for the echocardiogram by using their own sonographers. We expect to find that a technology-intensive system such as telemedicine will prove superior for delivery of neonatal cardiac diagnostic care for all measured medical and financial outcomes when compared to personnel- and time-intensive care delivery. It also may be possible to define the number of referrals or distance from the tertiary care center necessary to make one model of delivery more economical or time efficient compared to the other. By defining patient care and cost outcomes for these two models of neonatal cardiac care delivery, the results of this study will help tertiary care centers to design outreach cardiac care services that provide the best quality, most cost-efficient and time-efficient care in the future.

After results from this multicenter study are available, the advantages of telemedicine will be appropriately documented. This will open the door for expansion of telecardiology services to include many more outreach sites, resulting in improved medical care and cost efficiency for infants with suspected congenital heart disease.

Infants are not the only group who will benefit from telecardiology since this technology is already being applied in a limited way to older children with suspected heart problems. In addition, cost efficiency for both referring and tertiary care institutions due to the ability to decrease duplication of services and to centralize pediatric cardiac care will result in better ability to control medical costs. Expansion of this technology in the future will allow state-of-the-art medical care to reach many more neonates and children in geographically isolated, rural areas. This novel technology will be the basis for major improvements in infant cardiac care delivery not only regionally but nationally as well as worldwide. It will enable pediatric cardiologists to reach children both locally and through-out the world who in the past have died because of a lack of timely and affordable access to the expertise of a pediatric cardiologist.

REFERENCES

1. National Center for Health Statistics, 1996.

2. Wittson CL, Affleck DC, Johnson V: Two-way television group therapy. Ment Hosp 1961;12:22–23.

3. Sobczyk WL, Solinger RE, Rees AH, Elbl F: Transtelephonic echocardiography: successful use in a tertiary pediatric referral center. J Ped 1993; 122:S84–S88.

4. Fyfe DA, Emge F, Johnson G, McCaffery F, Luten W, Course D, Schrum A: Clinical validation of digital image compression levels for fetal echocardiograms for telemedicine. J Am Soc Echocardiogr 1995;8:345.

5. Perednia DA, Allen A: Telemedicine technology and clinical applications. JAMA 1995;273:463–488.

6. Alboliras ET, Berdusis K, Fisher J, Harrison RA, Benson DW, Webb CL: Transmission of full-length echocardiographic images over ISDN for diagnosing congenital heart disease. Telemed J 1996;2(4):251–58.

7. Fisher JB, Alboliras ET, Berdusis K, Webb CL: Rapid identification of serious congenital heart disease using real-time transtelephonic transmission of echocardiograms. Am Heart J 1996;131(6):1225–27.

8. Randolph GR, Hagler DJ, Khandheria BK, Lunn ER, Cook WJ, Seward JB, O’Leary PW: Remote telemedical interpretation of neonatal echocardiograms: Impact on clinical management in a primary care setting. J Amer Coll Cardiol 1999;34(1):241–245.

9. Berdusis K, Fisher J, Gidding S, Stapleton P, Alboliras E, Webb CL, Gotteiner N, Rocchini A, Duffy CE: The cost of providing telecardiology service over traditional outreach: A 2.5 year analysis. Telemed J 1997;3(1);96–7.

10. Webb CL, Dembski M, Berdusis K, Gotteiner N, Fisher J, Stapleton P, Alboliras ET: Telemedicine permits cost effective referral strategies for neonates with congenital heart disease. J Am Soc Echocardiogr 1997;10(4): 399.

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