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This article outlines the ways in which telemedicine has been implemented at a tertiary congenital heart disease centre
Thomas Witter RN (Child)
John Simpson MD FRCP FESC
Department of Congenital Heart Disease,
Evelina London Children’s Hospital
Guy’s and St Thomas NHS Foundation Trust,
The ever-increasing bandwidth of IP networks has facilitated the transmission of high-resolution images within institutions and from geographically remote sites to the specialist centre.1 The application of such technology to surgical practice, however, is impacted by many considerations in addition to the technical feasibility of image transmission. Rather than abstract consideration, this paper outlines the ways in which telemedicine has been implemented at a tertiary congenital heart disease centre, which undertakes almost 500 open-heart surgeries per year. Discussion of the clinical considerations for other telemedicine applications is also addressed.
The Evelina London Children’s Hospital receives referrals predominantly from the south of England but also from other parts of the United Kingdom and abroad. Around 20–25% of the patients who are operated on at our centre are quaternary referrals from other parts of the UK. The largest group are referred from Northern Ireland and so patients are flown across either by air ambulance or by commercial aircraft. One of the challenges of managing referrals from remote centres is how to have an interactive discussion with the referral unit with respect to the management options so that a final patient pathway can be agreed. The model we have adopted is that prior to transfer elective cases are discussed at a combined cardiology/cardiac surgical meeting. Use of a telemedicine link means that cardiologists in London and Belfast can jointly discuss cases with high-resolution images to agree patient management. This is exactly akin to the type of discussion which would take place for local patients and means that all relevant information is reviewed, the timing and type of cardiac surgery is decided and all other relevant clinical data are discussed together.2
One of the technical challenges is to allow rapid switching between the imaging modalities and ensuring a fast connection so that image resolution is optimal. The result of such joint discussion is that patients and families are well informed about the planned management in advance of transfer and further necessary investigation is agreed in advance, thereby minimising the time the patient has to stay at the surgical unit. Some clinical information, for example cardiac catheterisation images or CT scans, are transferred to our centre either by disc or increasingly by use of the UK National Health Service image exchange portal.3 This portal permits external imaging data to be transferred onto the in-house imaging archive so that it is readily available for review when the patient is transferred for surgery. Thus, the use of a combination of telemedicine and electronic image transfer achieves the goals of:
(a) Detailed discussion of individual cases between the referral unit and the surgical unit.
(b) Minimisation of admission time at the surgical unit.
(c) Availability of external imaging to the cardiology and surgical teams.
Such an arrangement requires the availability of the relevant staff at both centres and so is arranged at a fixed time each week.
Use of telemedicine techniques within a single hospital campus
Although the term ‘telemedicine’suggests transmission of images over long distances, the most frequent application of this technology at our centre has been within the hospital. This has been driven by the need for quality enhancement, time efficiency and effective deployment of staff. The majority of congenital heart operations are currently assessed by intraoperative echocardiography. This is done to visualise the cardiac anatomy and function both before and after surgery, whilst the patient is in the operating theatre. The published literature has shown that this improves outcomes by identifying residual heart lesions so that these can be repaired at a single surgical procedure. Oversight of such imaging in the operating theatre can involve the cardiologist having to change into theatre attire and assess the patient in the operating theatre. This can take upwards of 60–90 minutes or even longer if reoperation is required.
Over the past year we have introduced a telemedicine system, which involves connection of the cardiac ultrasound system in the operating theatre to a number of viewing screens at other sites in the hospital. The viewing stations allow senior cardiologists or other surgeons to visualise the ultrasound images in real-time and to discuss the findings with the surgeon, anaesthetist and the full surgical team (Figure 1). The use of microphones both on the viewing station and on the ultrasound system allows discussion between the surgeon and the cardiologist. This reduces the time taken to review such scans to around five minutes and also facilitates second opinions from other cardiologists in the unit. Thus, this achieves the double benefit of remote viewing of images and direct discussion between staff. Senior staff are more readily available than was previously possible and the staff time requirement is dramatically reduced. Our application of such technology has been in the field of congenital cardiac surgery but there is no barrier to such an approach being taken in other forms of surgery or other surgical disciplines.
Several facets of the introduction of this approach merit special mention. Firstly, the image quality of the transmitted video was assessed rigorously over the hospital network to ensure that the images were of diagnostic quality (Figure 2). This was done in an outpatient setting so that patient care was unaffected. Once the clinical staff were certain that the image quality was satisfactory (it was almost indistinguishable from the original) under test conditions, then the challenge was how to configure the ultrasound system to send the images via the hospital network. It is not possible to modify the ultrasound system by installation of further electronics within the cover of the system because this would mean that the CE marking of the system would be invalid.
Thus, the technical solution was to make use of readily available products and to install a Polycom Group Series video conferencing codec, microphone and audio speakers onto the rear shelf of our in theatre ultrasound system (Figure 1); along with the appropriate power isolation to maintain patient safety and medical device compliance. The video conferencing codec is designed to transmit/receive video and audio utilising an industry standard communications protocol (H.323).4 The codec was configured to automatically transmit the USS image from the auxiliary output upon initiation of a video call. For the user in theatre this simply means that there is one additional power cable and one additional network connection. From discussion with clinical users at the outset, it was clear that the system would need to be simple to use. Thus, connecting to the system in theatre was reduced to pressing two buttons on a viewing station (another H.323 codec, Figure 2) so that all clinical users could quickly and simply make use of the system. Six viewing stations were installed in convenient locations across campus.
Use of telemedicine on an emergency basis
The above applications of telemedicine assist in the planning and organisation of elective surgery and in monitoring of cardiac surgery within the hospital but they do not address the question of immediate availability of a specialist opinion on an emergency basis. To date, we have not established an “emergency” link because of a number of barriers in the context of cardiology practice. Firstly, for diagnostic images to be sent in real-time from a remote site, the imaging equipment (most commonly the ultrasound system) needs to be connected to the network and the network itself needs to be fast enough to send images of high temporal and spatial resolution. In paediatric cardiology, many of the remote assessments are performed on intensive care units or ward settings where the ultrasound system is not directly connected to the network. Wireless networking is rarely used in this setting although this is likely to change with recent advances in this area.
Other considerations are the immediate availability of the specialist at the referral centre to review the images being transmitted and to be able to talk directly to the healthcare professional who is sending the imaging information. Between institutions the technical aspects of such transmission need to be addressed with regard to secure access to networks, alongside information governance, which are an important consideration for transmission of patient identifiable data. Furthermore, there are major challenges complicating the use of telemedicine in an emergency setting.
Although openness about the diagnosis and prognosis of different forms of cardiac disease underpin our work, undertaking a “live” discussion of real-time scan images on the intensive care unit with a remote centre can be challenging. In the course of the telemedicine consultation, parents and relatives may be able to listen to the real-time consultation, which can include differential diagnosis and discussion of therapeutic approach and outcome. For these reasons, we have not adopted a live telemedicine approach to assess patients at remote centres on an emergency basis. Currently, the management of such patients is via conventional means such as discussion between the clinicians involved by telephone. Some remote institutions will send images promptly via the image exchange portal but this is variable between centres and, depending on the level of IT input required is not available on a 24/7 basis.
A similar approach to that outlined above is taken for ‘second opinion’ consultations between tertiary units. In this setting, there is direct telephone conversation between senior clinicians followed by image sharing either by the NHS Image Exchange Portal or by physical transfer of images on CD. A crucial aspect of such cases, however, remains direct discussion and detailed referral letters between institutions so that the particular considerations for each individual patient are understood. Such cases, where a second opinion is sought, tend to be complex and are normally subjected to the rigour of a joint cardiology/cardiac surgical conference so that consensus is reached with respect to optimal management.
In summary, telemedicine plays an important role in the discussion of complex surgical cases for elective cases referred from other centres. Within a single centre, the use of telemedicine can enhance quality and efficiency when the system is simple to operate, high quality and user-friendly. Use of telemedicine in an emergency setting continues to pose technical and clinical challenges within the context of cardiac care.