Telemedicine

A country like India , owing to it’s vast geographical spread and the enormous population, requires tremendous resources and well trained medical personnel so as to be able to deliver emergency medical care within a life-saving time frame in every nook and corner of the country. This may not always be possible given the fact that majority of the specialists are concentrated in urban areas with a significant paucity of trained specialists amongst the rural population. In a patient with a cardiac illness, the timing of medical intervention is crucial and dictates the outcome of treatment often proving to be the difference between life and death.

A typical example being the initiation of treatment early in a patient suffering a heart attack (golden hour), which can save life and have an important bearing on the quality of life post event 1. Considering the fact that a significant proportion of the Infant Mortality Rate of 63.19 per 1000 births 2 in our country could be attributed to the mortality associated with congenital heart defects, the burden posed by heart disease in the paediatric age group assumes enormous significance.

An estimated 48,000 to 1,28,000 babies are born every year with heart defects in India . This is based on the statistics that there are 16 million live births in India in a year and the incidence of heart disease in newborns is 8-12 per 1000 live births. Only a bare 5% of these obtain medical attention and surgical care. Nearly 65% will die below 1 year of age and only 15% will survive beyond the age of 5 years. With at least 50,000 new cases of Rheumatic fever every year, it is estimated that there are currently more than one million patients with rheumatic heart disease in the country, which only adds to the disease burden. To compound these problems, there are less than 15 trained pediatric cardiologists in the country and less than 10 institutions in the country with the requisite infrastructure and manpower to offer surgical correction for neonates and infants with heart defects. There are, also, not more than 10 dedicated pediatric cardiothoracic surgeons.

The mismatch between the medical need and the availability of specialist care in our country is thus clearly evident. As mentioned earlier, this is because there is an estimated 620 million population living in the villages and the availability of specialist doctors there is inadequate. For this reason, the rural population is known to be at twice the risk of death when compared to the urban population, for the same illness. Telemedicine can play a tremendous role in bridging the great divide between the patient and the medical specialist, especially in a country like India. By bringing together the patient and the specialist face to face and by its ability to allow the specialist to conduct an examination and view investigations both in report format and in real time, telemedicine allows a comprehensive medical consultation in the initial stages of the disease presentation without requiring the patient to travel long distances.

The basic requirement for tele-cardiac consultation is for a computer with a web camera, a modem and a standard telephone connection at the remote site with ISDN (Integrated Services Digital Network) or broadband capacity.

Auscultatory findings play a crucial part in diagnosing cardiac ailments, especially in those with congenital heart disease. Recent technological aids such as electronic stethoscope makes it possible for the clinician to hear the patients` heart sounds for himself across many miles and come to an accurate clinical diagnosis. This eliminates the risk of error associated with having to rely on the attending persons clinical auscultation. Even a narrow bandwidth (analog) telephonic stethoscope has been proven to be effective in distinguishing accurately between an innocent and a pathological murmur.3

The clinical diagnosis, thus arrived at, can then be confirmed by reviewing investigations such as electrocardiogram (ECG), Chest X-ray, Echocardiogram, Treadmill test, Angiocardiography, cardiac CT scan, cardiac MRI scan, ambulatory ECG monitoring, pacemaker evaluation, and relevant blood tests. Most of these test results are reviewed using a store and forward technique from the remote site, where the tests are initially performed, captured and stored in the computer which is then forwarded as still frames to the specialist for review.

Transtelephonic ECG provides the means of transmitting an electrocardiogram recorded in a patient with rhythm disorders or a myocardial infarction, enabling immediate initiation of treatment.

Having connectivity between an ultrasound (echocardiography) equipment and the computer, enables the transmission of streaming video pictures of the heart scan in real time to the specialist. This is particularly useful in situations where a child is brought in with a complex cardiac lesion. The primary doctor or technician may not be skilled to perform a detailed scan of the heart of the child and interpret them accurately, and in such cases the specialist is required to view the test liveto be able to make an accurate diagnosis. Telemedicine can be effectively used to transmit fetal echocardiography images as identifying fetal cardiac anomalies early on in gestation prepares the parents and the attending doctor towards care immediate post-partum thus greatly enhancing the outcome of management for that baby. As not many are trained to identify cardiac anomalies in early pregnancy, a technician could be directed by the clinical specialist at the referral center to show the required views to enable a diagnosis of fetal cardiac problem.

Chest X-ray and Echocardiography as transmitted by internet

The practice of diagnosing complex congenital heart defects by transmission over an ISDN line is well established. 4 However, in our experience, it was found that broadband or VSAT connectivity was superior to ISDN connectivity in that it enhanced the quality of the transmitted images as well as ensured an uninterrupted transmission, especially when transmitting streaming images such as online echocardiography. This is crucial for ensuring accuracy of the diagnosis, particularly in the case of a complex congenital cardiac anomaly. There are previous studies corroborating the accuracy of a diagnosis by telemedicine as compared to one by personal clinical examination. 5

Specialist viewing transmitted live echocardiography from a remote centre

In acute cardiac events, telecardiology provides the means by which the specialist is able to guide the primary doctor or the paramedical personnel at the scene to undertake measures which would help save the life of the cardiac patient based on the history provided, and the investigation findings. An extremely important aspect of telecardiology is that it achieves shared care of the patient by the primary physician and the specialist and also in the process entrains the primary physician in the ways of specialist management for the specific condition. Telemedicine can also be effectively utilized to propagate the knowledge of the specialist to primary care physicians and the public through teleconferencing continuing medical education (CME) programs.

APPLICATIONS IN RADIOLOGY

Images in Radiology are predominantly plain X-ray pictures, ultrasound scan images and images of CT scans, MRI scans, cine angiography etc. These images can be digitally scanned and stored in an archival server in DICOM (Digital imaging and communications in medicine ) format even if they are previously in non DICOM format. Subsequently the images can be stored in the web server in either compressed or non compressed form and be available for acquisition either within the institution through intranet or worldwide through internet. It is important to adhere to the DICOM-ACR-NEMA-3 standard for storing images and also important not to alter or edit the image during acquisition. Telemedicine plays a crucial role of networking whereby technicians in rural settings can acquire radiological images and transmit to a central hub where it can be reported on by a qualified radiologist and the report sent back to the primary physician in the rural center within a matter of minutes. Complicated imaging procedures or ultrasound guided procedures can be undertaken confidently in remote settings while being guided by a specialist from elsewhere be it within the country or from abroad.

RECOMMENDATION:

Accessibility to telemedicine centers can be enhanced if such models as the one in this study are developed on a larger scale networking the entire length and breadth of the country. This could be done with government and private sector partnership nurturing the way to establishment of a platform for dispensing uniform health care to one and all in the country despite the geographical restrictions.

References:

Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Boersma E, Maas AC, Deckers JW, Simoons ML,. Lancet 1996 Nov 9;348(9037):1312-3.
The world fact book 2001, CIA publication, Office of public affairs.
Accuracy of analog telephonic stethoscopy for paediatric telecardiology. Belmont JM, Mattioli LF. Pediatrics. 2003 Oct;112(4):780-6.
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.
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.

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