Ebook: Remote Cardiology Consultations Using Advanced Medical Technology

The Role of Advanced Medical Technology in Cardiology

NATO operations have expanded in recent years, and the old Cold War concept of “every nation provides its own medical support” is no longer tenable, nor is it NATO policy. In the future, NATO medical care will often be provided on a multinational basis, especially in case of emergencies such as NATO response to natural or man-made disasters or to terrorist actions. Even though deployed military personnel are usually young and relatively healthy, this is not the case for all those who may be provided care by NATO medical personnel. The pressures to “shorten the logistics tail”, coupled with the shortage of trained cardiologists in most of our nations, has and will continue to preclude the routine deployment of Cardiologists to all NATO operational missions. However, the need to provide services during these missions remains very real. Even following a natural disaster or exposure to toxic agents, the ability to distinguish a cardiac event from other causes of chest pain can be life-saving, and appropriate diagnosis will lead to improved survival, reduced inappropriate use of medical capabilities, and decreased inappropriate evacuation of patients.

Acute coronary syndromes (e.g. angina and myocardial infarction) and associated cardiac emergency conditions (e.g. arrthymias) remain the leading cause of death among industrialized nations, and deployed military personnel are certainly not immune from this threat. New diagnostic (e.g. portable ultrasound) and treatment modalities (e.g. fibrinolytic agents) have greatly improved the survival of the cardiac diseased patient, assuming the diagnosis can be made rapidly. Associated improvements in advanced medical technology and tele-communications, have enabled cardiac patients in remote or austere environments access to specialty consultation, even though the Cardiologist may be located elsewhere. This capability has resulted in decreased morbidity and mortality. Examples of this kind of second opinion consultation occur in the field of telehealth or telemedicine. In this case, cardiac patients in a remote site can undergo testing and evaluation with an electrocardiogram (ECG) or echocardiogram (ECHO) captured in a digital format, which can then be forwarded over commercial communication networks to a medical center for interpretation by a cardiac specialist. Supplementation of this capability with real time transmission of a patient examination with heart sounds (tele-stethoscopy) or videoteleconferencing (VTC), may augment the medical evaluation and provide the remote medical provider immediate referral recommendations that can be life-saving.

In the military setting, deployed NATO forces in remote locations (e.g. Kosovo) are comprised of young as well as middle-aged forces that are susceptible to suffering an acute cardiac event. These deployed sites typically do not have a cardiologist available at the remote medical treatment facility. Often, if two-way voice communication is established, cardiac specialists can be consulted with a limited view of the cardiac patient. Increased bandwidth availability is now becoming possible in remote deployed environments and permitting the use of tele-consultation in a variety of medical disciplines. Advanced medical technologies (digital cardiac ECG and ECHO machines) in the field of cardiology have been developed and are routine in the management of cardiac patients. Other enabling technologies include advances in compression of digital data allowing transmission of large data files over low bandwidth systems (e.g. Internet) as well as increased availability of large bandwidth systems using satellite technologies.

Many nations and agencies currently have ongoing research in this field, including the US, France, Spain, the Netherlands, Norway, Croatia, the European Commission, and the World Bank. There is a scientific need to bring many of these researchers together to discuss mechanisms for interoperability, and to begin the discussions about Telecardiology Standardization to allow regional and other multinational mutual support. In Croatia, the need for remote tele-cardiology consultation is necessary in order to meet the growing demand for expert medical advice for tourists vacationing in remote islands in the Adriatic Sea who take ill with a cardiac event. To address this concern in Croatia, a World Bank funded initiative in the field of tele-cardiology was approved and work is already underway to meet this need. The Croatian Ministry of Health is the stakeholder organization shepherding this initiative. Likewise, in the US military, transmission of digital ECG's and ECHO images is occurring in medical treatment facilities in the continental United States but infrequently in operational settings such as Iraq or Afghanistan.

In September 2005, a NATO sponsored Advanced Research Workshop (ARW) titled “Remote Cardiology Consultations Using Advanced Medical Technology – Applications for NATO Operations” was conducted in Zagreb, Croatia and provided a forum to discuss the advances in diagnostic medical technologies as they apply to the specialty of cardiology. Experiences gained from NATO forces in both garrison and deployed environments were shared. Lessons Learned from an international community in the field of tele-cardiology were identified with far-reaching impact as new systems are developed and deployed in future NATO missions.

The ARW consisted of several panel presentations over three days drawing from experts in health, clinical research, electrical engineering and law. The main focus of the meeting was to:

a. address the clinical need for tele-cardiology in a remote or austere environment;

b. to assess cost-effective technical solutions with “off the shelf” hardware and non-proprietary software;

c. to articulate the human factors challenges in developing regional cardiac consultation;

d. to identify the legal, regulatory, and security concerns for remote tele-consultation; and

e. to develop a business case analysis for tele-cardiology that will allow self-sustainment of services based on sound economic expectations.

The efforts of this meeting culminated in the development of this book which summarizes the current state of Telecardiology as presented by the member participants totalling nearly 60 individuals and representing over 16 NATO and Partner for Peace nations. We thank the meeting participants and the Organizing Committee for their tireless efforts in successfully conducting the meeting and preparing their manuscripts for inclusion in this book. We especially thank the NATO Advisory Panel on Security-Related Civil Science and Technology and the Assistant Secretary General for Public Diplomacy, for their financial award, without which this meeting could never have occurred.

NATO country co-director, COL Ronald Poropatich, MD, US Army Medical Research & Materiel Command, Telemedicine and Advanced Technology Research Center, Fort Detrick, MD, USA

Partner country co-director, Professor Ivica Klapan, MD, PhD, Croatian Telemedicine Society of the Croatian Medical Association (President), Telemedicine Committee-Ministry of Health and Social Welfare, Republic of Croatia (President), Department of ORL-H&N Surgery, Zagreb University School of Medicine & Clinical Hospital Center Zagreb, Šalata 4, HR-10000 Zagreb, Croatia

This article describes the Spanish Military Telemedicine system and specially the role of the Telecardiology on it. Terrestrial wide area networks and satellite connections are used for cardiologic Teleconsultations and for clinical meetings. Coronariographies, ultrasound and the most of the cardiologic examinations are transmitted by these system. Some investigations on Telecardiology are on developing.

This article is summarising trend and technologies which might be usefule for establisment of differen solution aplicable in area of Telemedicine/Telecardiology. Additionally some working assumption and support definitions are presented to be able to outline a posible integration strategy of telemedicine solution within a trully intrgrated information technology system what is an ultimate goal of every leading heath care organisation.

The paper addresses telemedicine, as a tool which enables better medical services to patients around the world, in its legal and policy context. In order for this new area of medicine to function properly, providing a safe, desirable and high-quality environment, technological developments should be followed, if not preceded, by legal and policy documents, thus avoiding any misuse, legal uncertainty and risks. The paper represents a screening exercise of the EU and Croatian legal and policy documents in this area and pinpoints problems and challenges faced today. The discussion shows not only where we are standing at this point, as regards legal and policy aspects of telemedicine in the EU and Croatia, but also suggests where we are heading and what our goals are. Any future developments in telemedicine require the establishment of all legal and policy preconditions for its safe practice.

The aim of this paper is to present in brief the attempts to develop a user-friendly environment for tele-cardiology consultations in a rural area as part of pilot project 7- BUL/03/001 co-funded by Bulgaria and International Telecommunication Union (ITU), Switzerland. The project is in its first half. The emphasis on tele-cardiology (monitoring and transmission of ECG, blood pressure and heart rate data) is due to the fact that cardiovascular diseases are leading cause of death in the country. The examination of vital cardiovascular parameters is the first and that's why the most often used tool providing clues to cardiovascular problems. Precise monitoring of these parameters is a good method to reveal first symptoms of coming myocardial infarct or other cardiovascular complications. Groups that will benefit from telecardiology application are patients suffering from cardiovascular diseases; patients on medications, which may affect the heart and elderly.

The field of advanced medical technology is rapidly changing, so much that the concept of what the future holds has changed radically in recent years. That which was seen as “cutting edge” a few years ago has now become almost routine. Some of the newer concepts currently being researched by the U.S. Army's Telemedicine and Advanced Technology Research Center (TATRC) which may prove to be the drivers for new medical applications and business practices will be discussed.

Background: Heart murmurs are found in more than 50% of children, yet less than 1% of children are born with congenital heart disease. The auscultation skills of the general practitioners responsible for routine child care are suboptimal, however, leading to frequent referral to pediatric cardiologists for evaluation. Pediatric cardiologists can quickly and accurately diagnose innocent murmurs with physical examination only, thereby avoiding further diagnostic testing. Patients living in remote regions without pediatric cardiology support require evacuation to medical centers, which can delay diagnosis, lead to family stress, and result in significant financial expenditure for travel. Using a digital recording stethoscope and our store-and-forward telemedicine system, we developed a pediatric telecardiology system to allow for remote cardiac auscultation. We hypothesized that such a system could accurately classify auscultatory findings as normal/innocent murmur or pathologic, thereby reducing the need for many evacuations and allowing more timely evaluation of patients with cardiac pathology.

Methods: Patients undergoing evaluation in the pediatric cardiology clinic at Tripler Army Medical Center underwent standard physical examination and complete echocardiography to establish a definitive cardiac diagnosis. Using a commercially available digital stethoscope attached to a handheld PDA, study participants also had 20-second digital heartsound recordings acquired from standard cardiac auscultation areas while both upright and supine. Heartsounds were uploaded to our store-and-forward telemedicine system, allowing for playback in a manner similar to standard clinical auscultation via a custom graphical user interface. Pediatric cardiologists, blinded to all other clinical information, evaluated each heartsound dataset and classified the case as either normal or pathologic.

Results: To date, 41 pediatric patients have been evaluated (24 with normal/innocent murmurs, 17 with cardiac pathology), each of which interpreted by 3 pediatric cardiologists (total of 123 cases). When compared to echocardiographic results, 86% (106/123) of the cases were accurately classified as either normal/innocent murmur or pathologic. Nine cases with pathology were misclassified as normal/innocent murmur (sensitivity 84%). Eight cases were classified as pathologic (specificity 88%) when the findings were normal/innocent murmur.

Conclusions: Digital heartsound recordings evaluated in our store-and-forward telecardiology system can determine normal from pathologic auscultatory findings with a high degree of accuracy. Such a system has the potential to significantly decrease travel expenditures and reduce diagnostic delays for patients requiring pediatric cardiology evaluation. Further refinements to our heartsound system are in progress and are expected to further improve the accuracy of remote cardiac auscultation.

Background: Echocardiography is important in examining various cardiac conditions and, in particular to verify heart failure. It is seldom performed in a primary care centre (PHC) setting, especially not in sparsely populated areas. Aim: To develop a concept that enables long-distance real-time echocardiography, preferably in rural PHCs.

Method: A robotic arm (Mobile Robotics AB, Skellefteå) has been developed to which an ultrasound probe is connected. A mobile ultrasound unit is placed at the patient's primary care site. A broadband link between the patient and the ultrasound operator is required in order to view the patient and the exact position of the probe, microphone, monitors and loudspeaker. The operator controls the robot and the ultrasound machine remotely with a joystick with the aid of newly developed software (Alkit Communication AB, Luleå). The ultrasound machine software is also remotely controlled by a virtual keyboard. Consultation between specialist, primary physician, operator and patient is done directly after the echocardiographic examination.

Result: Trials have been completed between the following locations: Luleå-Arvidsjaur (150 km), Umeå-Skellefteå (140 km) and Gothenburg-Skellefteå (1300 km). The procedure has provided satisfying results regarding long distance communication and image quality. However, more tests are necessary to evaluate patient satisfaction, cost-effectiveness and potential benefit for the health care system.

Conclusion: It is feasible to perform real-time echocardiography at a long distance by using present-day information technology (IT) and robotics. Echocardiography and specialist consultation with the patient can be done concurrently. In the future this concept might provide the opportunity for patients in rural areas to get rapid and accurate diagnosis and management of heart diseases.

As the North Atlantic Treaty Organization has evolved its doctrine from that of strictly national medical support during operations to that of multinational medical support, the importance of, and the need for, Telemedicine standardization has become apparent. This article describes the efforts made by NATO in recent years to begin the process of Telemedicine (TMED) standardization within the Alliance.

Background: The high mortality in Poland due to the diseases of cardiovascular system (ca 50% of the total mortality) is the motivation for the presented work. Fight against those diseases is incorporated into e-health strategy for Poland for 2004-2006 and also into the National Program of Health. The interventional cardiology (angioplasty, sent implantation) combined with telecardiology can shorten the treatment delay and improve the outcomes of acute coronary syndrome (ACS) patients.

In Poland the interventional cardiology is performed only in big metropolitan centers to which the patients from smaller towns and rural areas need to be transported. Our system is addressed especially to those patients.

Aim: The aim of the work is the design and implementation of the prototype telecardiological system in Mazovia District (100 km radius around the capital Warsaw) with possible extension to other districts. Also improvement of cooperation among cardiological centers and rationalization of the specialized clinical resources and access to unified digital archives can be mentioned as the aims. The aim of medical importance is the reduction of time from symptoms to intervention which can possibly reduce mortality.

Methods: The overall structure of the system consists of 3 layers:

1 – reference (invasive cardiology) center, 2 – regional centers (hospitals), 3 – ambulance network. The software tools for communication among centers are Electronic Patient Record (EPR), accessible via Internet, relational data base MySQL in which EPR's are stored and expert system (ES) for risk assessment and advice on non-pharmacological and pharmacological treatment.

Result: EPR has been created up to now for over 100 patients. The data were stored in the database. ES performed risk stratification for each patient. It is based on the voting system in which risk scores such as SIMPLE, TIMI, GRACE, ZWOLLE are integrated with B-type natriuretic peptide (BNP). The patient is assigned to either low or high risk group which affects the choice of the type of treatment. ES evaluates also indications or contraindications for pharmacotherapy. Inter-rater agreement between a physician and ES was assessed by statistic kappa and was found either good (kappa 0,61-0,8) or very good (kappa 0,81-1).

Conclusion: The main elements of the system - EPR, database and ES are functioning properly. The regional centers require support in terms of staff training in EPR and database operation and also attention to the hardware, software and Internet access has to be paid for. Ambulance network is a crucial factor in improvement of healthcare of the ACS patients. Better cooperation among the regional and reference centers is required and also equipment for ECG data transmission over mobile phones.

The foreseen benefits of the system use are:

- better access to healthcare for the patients from rural areas and small towns,

- shortening the consultation time between ambulance/regional center and reference center which translates into shorter time from symptoms to intervention.

Cardiovascular disease (CVD) has emerged as the dominant chronic disease in many parts of the word. At the beginning of the 21^st century, CVD account for nearly half of all deaths in the developed world and about twenty five percent in the developing word. Cardiological Service in Republic of Moldova is a structure relatively young and it is in permanent reshape. There are no national data on the real number of cardiac patients. Epidemiological studies of terrain (1998–2002) have shown that there are enormous differences of usage of new technologies in different regions. We have big problems with insufficient financing of health and public cardiological service. The future national Program of prevention and treatment of CVD will have the aim to contribute to find out all of cardiac patients and distinguish the groups of high risk from the healthy population. Based on the epidemiological situation we need to elaboration some national project, including as e-health, Telemedicine/Telecardiology for implementation in our health system.

Telecardiology is a telemedicine service that can provide expert consultation and life-supporting treatment to patients independent of geographical location. The required technology has been available for many years, but the diffusion of telecardiology services is still limited. With the aging population of the industrial world and the increase of chronically ill patients, there is a need for telecardiology services. This paper presents a survey on how telecardiology services are being used today. The survey was conducted by reviewing articles published in recognized journals and conferences and categorizing them according to a telemedicine taxonomy, which was extended for telecardiology purposes. Based on the survey results, interoperability issues are discussed and also how standardization may change the pattern for use of telecardiology. Our principal results are that very few publications describe mobile telecardiology services that facilitate wireless communication. More research needs to be conducted on mobile telecardiology services and interoperability issues on information and communication levels must be worked out.