Summary

In July 1998,a telemedicine link was established between the Venizelio General Hospital in Crete and the Paediatric Cardiology Department of the Aghia Sophia Children's Hospital in Athens. The telemedicine link used ISDN at 384 kbit/s for diagnosis, management and education in congenital heart disease. Over 18 months, a total of 39 teleconsultations were carried out, concerning 93 children with haemodynamically significant cardiac abnormalities. Forty-four children (47%) were managed locally after teleconsultation, while three children with transposition of the great arteries (3%) were transported as emergency cases to Athens in the first days of life. The other 46 children (50%) had a scheduled appointment ata tertiary centre for cardiac catheterization, angiocardiography, operative treatment or surgical repair. The telemedicine link brought a number of benefits, such as better access to the tertiary centre and the avoidance of patient transportation.

Introduction

Telemedicine can be used to improve the management ofa patient ina remote centre where the necessary medical expertise is not available. Telemedicine has been used in numerous fields, including cardiology and paediatric cardiology. Telecardiology has been used for many years, for example for the transmission of electrocardiograms (ECGs) in order to monitor implanted pacemakers. In the field of paediatric cardiology, delays in either the diagnosis or the management of a major cardiac abnormality may increase morbidity and mortality rates. Furthermore, the transportation ofa critically ill child from a remote area to a referral centre involves risk, delay and expense. Hence, telemedicine may become an important tool in clinical practice under such conditions.

In 1998,a telemedicine link based on ISDN telecommunication was established between the Venizelio General Hospital on the island of Crete and the paediatric cardiology and cardiac surgery unit of the Aghia Sophia Children's Hospital in Athens. The distance between the two hospitals is approximately 320 km. Crete is an island witha population of 540,000, of whom 115,000 are children. Given that congenital heart disease has an incidence of approximately 8-9 per 1000 live births and that there are about 6000 births in Crete each year, it may be estimated that about 50 babies are born in Crete each year with congenital heart disease. There is no specialized medical centre with a paediatric cardiology unit in Crete. The urgent transportation of a neonate with a major cardiac defect may be either hazardous or not feasible, owing to bad weather conditions or the critical situation of the patient. The cost of the air transport of the patient, plus the travel and accommodation expenses of the parents and their lost income, add a significant financial burden to families with children suffering from congenital heart disease.

The telemedicine project aimed to improve patient care by providing realtime medical consultation and follow-up by medical experts. In an emergency, the experts of the specialized medical centre would either suggest a treatment plan for the baby at the local hospital or advise the urgent transportation of the patient to the referral centre. Immediate access to a specialist's opinion may modify the management plan of the patient and avoid morbidity or unnecessary, costly treatment. In non-urgent situations, patients would benefit from a consultation for a second opinion on the treatment of their disease, without the need to travel to the tertiary centre. The same infrastructure could also be used for distance education and training of the staff at the peripheral centres.

This preliminary communication reports our initial experience with telemedicine for remote diagnosis, management and education in congenital heart disease.

Fig 1 Two-dimensional echocardiogram imaging the ventricular septal defect and the overriding aorta in a patient with tetralogy of Fallot.

Methods

A telemedicine link was established between the Venizelio General Hospital of Crete, a general secondary hospital, and the paediatric cardiology and cardiac surgery department of the Aghia Sophia Children's Hospital of Athens, a tertiary hospital. In addition, telemedicine connections were established with three other hospitals, the Royal Brompton Hospital in London, the Santa Cruz Hospital in Portugal and the University Hospital of Patras, Greece.

Each hospital was equipped with a videoconferencing unit (Vision 2000, Tandberg) capable of a frame rate of 30 frames/s, a document camera (VID-P100, Sony), a video-recorder (SVO-1500Ρ, Sony) and a videocamera (CCD-TRV 35Ε, Sony). An electronic database (Access, Microsoft) was used for the patient data. The echo studies were performed using an ultrasound scanner (Sonos 5500, Hewlett Packard) and all the images needed for the diagnosis were transmitted live or recorded. The use of three ISDN lines (a bandwidth of 384 kbit/s) proved satisfactory for the realtime transmission and interpretation of echocardiograms and angiograms, with little degradation of the quality of the images.

Before proceeding to clinical use, the quality and consistency of image transmission were tested in a blind study. Six paediatric cardiologists interpreted the transmitted and original data from 56 patients (aged from 20 weeks' gestation to 29 years). The data included 38 angiocardiograms, 30 echocardiograms (fetal, transthoracic and transoesophageal) and 46 ECGs. There were no interpretation differences between the original and the transmitted studies, and the transmitted images were considered to be of diagnostic quality.

At the Venizelio Hospital the echocardiograms (see Figs 1, 2) were performed by a paediatrician with experience in congenital heart disease and echocardiography. During scheduled teleconsultations, mainly for re-evaluation of patients or follow-up, pre-recorded echo examinations were transmitted using the link. Records of all transmissions were kept prospectively. Indications for echo transmission included children with significant congenital heart disease that required access to a tertiary centre, either urgently or non-urgently. These echocardiograms represented postoperative follow-up studies, assessments of disease progression in children with known congenital heart disease, or diagnostic examinations of a cardiac abnormality in a new patient.

Fig 2 Continuous-wave Doppler display across a severe coarctation.

Results

During the 18-month study period, from July 1998 to December 1999, 39 teleconsultations were carried out, concerning 93 children with haemodynamically significant cardiac abnormalities. Realtime transmission was used for 17 patients and pre-recorded video-images for 76 patients.

There were 33 teleconsultations between the Venizelio Hospital and the Aghia Sophia Hospital, aimed at confirmation of diagnosis and appropriate management. The mean duration of the teleconsultations was 15 min per child.

There were two teleconsultations between the Venizelio Hospital and the University Hospital of Patras, concerning the management of children with arrhythmias.

Four teleconsultations were performed between the Venizelio Hospital and the Royal Brompton Hospital, for educational purposes.

Of the 93 children evaluated by telemedicine, 54 were boys (58%) and 39 were girls (42%). Their mean age was 4.1 years. The age distribution of patients is shown in Table 1 and their diagnoses in Table 2. Seventeen children (18%) had a major congenital heart disease (Table 3). The majority of the children with a severe cardiac defect were transported to a tertiary centre either urgently or non-urgently for surgical repair; two of these children later died. Of the 93 children, four had no cardiac abnormality (4%).

The images were consistently of diagnostic quality. In none of the 49 cases (53%) in which repeat studies were performed in the tertiary centre were important discrepancies in diagnosis found, although there were some minor omissions (Table 4).

Table 1. Age distribution of the children

Table 2. Diagnoses of the children, as estimated by telemedicine

Table 3. Children with major congenital heart diseases

Table 4. Diagnoses in 49 repeat studies at a tertiary centre

Forty-four children (47%) were managed locally after teleconsultation, while three children with transposition of the great arteries (3%) were transported as emergency cases to Athens in the first days of life. The other 46 children (50%) had a scheduled appointment at a tertiary centre for cardiac catheterization, angiocardiography, operative treatment or surgical repair.

Discussion

Rapid and accurate diagnosis of congenital heart disease is important to avoid high morbidity and mortality rates among these patients. Echocardiography is the most important tool used by paediatric cardiologists for the diagnosis of life-threatening cardiac defects and represents an essential part of the diagnostic assessment of the newborn, but few hospitals have the specialist staff to interpret such studies. Before the installation and operation of the telemedicine system, echocardiograms were sent on video-tape via overnight courier to a tertiary centre for interpretation. In emergency cases, babies were transferred for further diagnosis and treatment to hospitals with advanced care facilities. In contrast, with the implementation of the telemedicine link, immediate access to specialists was possible. The echocardiograms were performed at the patient's bedside and guided by the medical specialist from the tertiary centre when necessary. An advantage of realtime transmission as opposed to pre-recorded video-tape is that the cardiologist who interprets the images can have all the necessary views even when the imaging is being performed by unskilled staff. Moreover, the paediatrician who performs the echocardiogram at the local hospital can obtain immediate confirmation of the diagnosis, while at the same time receiving valuable, if informal, education and training.

At the end of the teleconsultation an agreement can be reached regarding patient management, and this will often result in the patient being treated locally and avoiding transportation to the tertiary hospital. In emergencies, the medical teams at the tertiary hospital will have all the necessary information in advance and so will be able to treat the patient immediately on arrival, without the need for any further assessment.

During the present study, 44 children (47%) were managed locally and so, as a result of the teleconsultation, avoided transportation. In addition, 46 children (50%) had a scheduled appointment at a tertiary centre for further evaluation and treatment. These children were transported non-urgently to

Athens, thus reducing the risk and inconvenience to the patient and family, and also saving resources. Only three children (3%) with a major cardiac defect were urgently transported to a tertiary centre.

Our experience confirms the diagnostic accuracy and cost-effectiveness of echocardiographic transmission from remote sites to specialized hospitalsb-10. In our study, the transmitted images were of sufficient quality, as shown by the cases in which repeat studies were performed in the tertiary centre: there were no important discrepancies in diagnosis, although there were some minor omissions.

The cost of buying the equipment plus its installation was US$16,250 per site (US$1 is EU1.05). The telecommunication cost between Athens and Heraklion was $50/h. The average time spent per patient was 15 min. Thus, the telecommunication cost was $12.5 per patient. The minimum travelling expenses from Heraklion to Athens for a child with its parents plus accommodation in Athens for one day were $440, not including any lost income of the parents because of absence from work. That is, the variable cost of telemedicine was much lower than the variable cost of patient travel. It therefore seems likely that within 18 months of operation of the telemedicine service there was a substantial saving of social resources.

Another benefit of the telemedicine system was the opportunity for workers separated by a considerable distance to take part in teleconferences and share experiences. Application of telemedicine in a general hospital, where a paediatric cardiology unit is not available, contributes to the proper management of children with congenital heart disease, and avoids delays in treatment and unnecessary transportation.

Acknowledgements: The authors are grateful for the support provided by the Directorate General Information Society of the European Union, which funded 50% of the costs of the TELEREMEDY project.

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Telemedicine and Telecare, 2001; 7: 239-243
Amalia Tsilimigaki*, Sophia Maraka*, Theofani Tsekoura*, Vasiliki Agelakou*, Athina Vekiou, Chris Paphitis and Vasilis Thanopoulos
*Venizelio General Hospital of Crete; Aghia Sophia Children's Hospital of Athens, Greece
Accepted 1 February 2001
Correspondence: Amalia Tsilimigaki, Paediatric Clinic, Venizelio General Hospital of Crete, Irodotou 214, GR-71601 Heraklion, Crete, Greece
(Fax: +3081 214 459; Email: sava@hol.gr)
Τελευταία αναθεώρηση : 1/1/2006