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Pediatric Update

 
Summer 2007

Telemedicine Increasingly Popular As Technologies Improve

Telemedicine Increasingly Popular As Technologies Improve

With specialization increasing in certain areas of pediatric medicine and the technology for high-speed transfer of data becoming more available, telemedicine is taking on a more prominent role as a cost-effective way for community facilities to improve their quality of care, particularly as it pertains to diagnosis via imaging studies.

Telemedicine is loosely defined as the use of electronic information and communication technologies to remotely provide medical information and services. In rare cases, it is employed for interventions such as robotic surgery. More commonly, the technology is used as an educational tool— such as live video presentations at conferences—and for the evaluation of imaging studies from distant sites.

The latter use is growing rapidly in the field of pediatric cardiology. “As our noninvasive diagnostic techniques improve, people are becoming experts in very narrow areas of medicine, and telemedicine is a costeffective way for smaller hospitals and institutions to provide high-level care by taking advantage of this expertise,” says Kevin Shannon, M.D., UCLA pediatric cardiologist.

For example, Dr. Shannon explains, if a hospital that lacks a pediatric cardiologist on staff has an infant patient with a heart murmur, the facility would have to pay for a consultation in order to make it worthwhile for the specialist to drive to the hospital and read the echocardiogram. In cases where the echocardiogram turned out to be normal, the consultation wouldn’t have been needed. “If someone could read the echo from far away and report that it’s normal, you save the additional cost of the consultation,” Dr. Shannon notes. “That way, the hospital doesn’t always have to keep someone on staff or on call with privileges for consultation.” Dr. Shannon notes that there are now certain specialists who only read echocardiograms, and thus become highly skilled at differentiating normal variance from pathologic problems on the readouts. Small facilities can contract with these individuals to interpret the images quickly and concisely, regardless of distance.

Radiology is a specialty that has always been ideally suited for the practice of telemedicine, notes Craig Morioka, Ph.D., UCLA radiological scientist. The most common application oftelemedicine in radiology is known as teleradiology— the transmission of medical images to a remote location for interpretation. “Emergency departments, off-site outpatient imaging centers and even rural hospitals are utilizing picture archiving and communication systems (PACS) to send images to radiology departments for immediate interpretations and/or second opinions,” Dr. Morioka says.

The primary scenarios for the use of teleradiology, he adds, involve offhours interpretation of radiologic studies in emergency departments. Emergency-room physicians also use real-time teleradiology consultation to a radiology specialist in the diagnosis of the patient’s condition based on the imaging study. Second opinions and over-reads are also performed via teleradiology when the junior radiologist is unsure of the diagnosis and requires an expert opinion. Dr. Morioka cites a March 2000 survey by Academic Radiology indicating that 60 percent of 287 academic radiology departments provided teleradiology services.

Two major developments have facilitated the telemedicine trend, Dr. Shannon says. High-speed T1 and Ethernet lines enable the transfer of large quantities of information rapidly, dramatically expanding the types of studies that are available for telemedicine. “It’s no longer just single-frame X-rays that can be transferred; it’s now almost any medical imaging study, in near or actual real time,” says Dr. Shannon.

In addition, the improved nature of the imaging machines has made it easier to acquire good-quality images. “Most imaging studies require less expertise than they did 10 years ago,” says Dr. Shannon. That means hospitals don’t have to hire someone with a tremendous amount of experience in the technique; they merely need to access an expert in reading the results.

For these reasons, the reading of neonatal echocardiograms has emerged as the primary utility for telemedicine in pediatric cardiology, Dr. Shannon says. The images can be acquired with minimal expertise and read in real time. If necessary, the technologist can be asked to acquire additional images from different angles. UCLA has contracts with neonatal intensive care units at a number of community hospitals to read imaging studies. All pediatric echocardiograms taken at two facilities are also sent electronically to UCLA Medical Center.

“This is improving the quality of care at many institutions,” says Dr. Shannon. “For a lot of community and non-tertiary hospitals, it means that they can, in a very cost-effective way, provide almost immediate diagnosis of potentially life-threatening conditions, as well as for conditions in which the treatment may have some risks. It shortens the time to diagnosis and therapy, which translates to better care.” Whereas in the past babies were frequently transported for diagnostic purposes, that is almost unheard of since the emergence of telemedicine, Dr. Shannon notes.

While telemedicine is almost exclusively used for diagnostic purposes rather than interventions, Dr. Shannon points out that the diagnosis is often the most important factor in deciding what type of therapy or transport is required. For the purposes of making a diagnosis, he adds, echocardiograms read via telemedicine are the equivalent of those done on site.

Dr. Shannon expects telemedicine’s applications to expand. Soon, Dr. Shannon predicts, three-dimensional images of the heart will be acquired and transferred to physicians who will be able to manipulate the results to see what they need.

As the technology continues to improve, and the cost is reduced, telemedicine may also be employed as a vehicle for using echocardiograms to screen the population. “When we start doing screening-imaging studies, there are going to be so many studies that will need to be read in such a relatively short period of time that telemedicine will be the only costeffective approach,” Dr. Shannon says. Thus far, screening echocardiograms have been proposed only for preventing sudden death among athletes. But athletes are at only slightly higher risk than non-athletes, Dr. Shannon notes. In addition to making screening more cost-effective, telemedicine would likely reduce the rate of false positives by ensuring that the studies are read by experienced professionals.

“We’re moving toward more centralization of expertise, and as that happens telemedicine is going to enable a broader distribution of that expertise and require less travel by patients to access it,” Dr. Shannon concludes. “In the not-too-distant future there will be machines to acquire images just about everywhere, but probably only a limited number of centers that read those studies. For that reason alone, telemedicine is going to expand.”

Recommended reading

Ebbert TL, Meghea C, Iturbe S, Forman HP, Bhargavan M, Sunshine JH. The state of teleradiology in 2003 and changes since 1999. AJR Am J Roentgenol. 2007 February; 188(2);W103-12.

Lester N, Durazzo T, Kaye A, Ahl M, Forman HP. Referring physicians’ attitudes toward international interpretation of teleradiology images. AJR Am J Roentgenol. 2007 January; 188(1);W1-W8.

Lewin M, Xu C, Jordan M, Borchers H, Ayton C,Wilbert D, Melzer S. Accuracy of pediatric echocardiographic transmission via telemedicine. J Telemed Telecare. 2006; 12(8); 416-21. Sable C. Telemedicine applications in pediatric cardiology. Minerva Pediatr. 2003 February; 55(1); 1-13.





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