Telemedicine for Paediatric Cardiology: practical experience using ISDN-6

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Telemedicine for Paediatric Cardiology
practical experience using ISDN-6 ISDN-2
technology
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• Gwyn Weatherburn
• Reader in Medical Imaging
• Research Centre for Health Studies
• Buckinghamshire New University
• Mike Rigby
• Consultant Paediatric Cardiologist
• Royal Brompton Hospitals NHS Trust

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• Dejan Mijin
• Research student, BNU
• Jovan Kosutic
• Paediatric Cardiologist,
• Mother Child Institute, Belgrade
• Tom Carter
• Telemedicine Co-ordinator
• Royal Brompton Hospitals NHS Trust

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ISDN-6 or ISDN-2?

• Integrated Services Digital Network
• Each line has a transmission rate of 64 kb/s
• ISDN-6 provides 384 kb/s
• ISDN-2 provides 128 kb/s (15 frames/sec)

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ISDN-6 or ISDN-2?

• How many lines are needed for
  paediatric cardiology?

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Royal Bromptons experience with ISDN-6 for
paediatric cardiology

• RBH has used ISDN-6 technology for many years
• For the last 9 years, RBH has provided advice to
  Brazil, Greece and Portugal using ISDN-6
  technology
• More recently, in the UK, RBH has provided advice
  to 4 DGHs using ISDN-6 teleconference equipment
  for the TelePaed study

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TelePaed

• Department of Health funded evaluation of the
  cost effectiveness of TM for the provision of
  Specialist Foetal and Paediatric Cardiology
  advice by Specialists at RBH to Obstetricians and
  Paediatricians in four DGHs
• The 4 reports of this study are available (Dowie
  et al)

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Typical ISDN-6 teleconference equipment
Video recorder/player for echo examinations
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Accuracy of decisions made during teleconferences

• Audits have shown the suitability of ISDN-6
  to enable correct diagnosis and management
  decisions to be made about difficult or
  complicated cases
• But can such decisions be made using lower
  transmission rates?

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RBH and Belgrade study using ISDN-2 technology
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Research hypotheses

• When ISDN-2 technology is used to provide a
  clinical service to link clinicians in Belgrade
  with RBH (1800 miles)
• The clinical service is acceptable to all
  clinicians
• There is change in diagnosis
• There is change in patient management

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Equipment

• At Royal Brompton (RBH),London
• ISDN-6 existing teleconferencing technology was
  used
• At Mother Child Institute (MC), Belgrade
• an ISDN-2 line was installed
• an ISDN-2 videophone was loaned by BNU

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WIRING REQUIREMENTS
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Viewing equipment for radiographs, ECGs etc
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The teleconferences

• Live discussions between clinicians without
  patients present commenced in December 2003
• Transmission and discussion of
• recorded echocardiograms,
• radiographs,
• ECGs

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Ultrasound examinations

• Pre-recorded cross sectional echocardiograms as
  routinely used by paediatric cardiologists,
  conventional
• Subcostal,
• Apical parasternal,
• Suprasternal images

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Results

• To September 9th 2004, there were
• 6 consultations during which,
• 17 patients were discussed

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Results

• Picture sound quality was usually good
• Connection time was short (lt 1 min)
• Mean discussion time for each patient was about
  15 mins

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Results

• NB. Data missing for one patient

Yes No
Echo viewed 14 2
ECG viewed 8 8
Xrays viewed 11 5
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Effect of teleconsultation on diagnosis
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Management changes after teleconsultation
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Some of the medical conditions discussed (some
children had multiple abnormalities)

• ASD
• VSD
• Aorto-pulmonary collateral vessels
• Pulmonary artery stenosis
• Aortic valve stenosis
• Aortic coarctation

• Fallots Tetralogy
• Mitral valve atresia
• DORV
• Pulmonary atresia
• Mitral regurgitation
• Cardiomyopathy
• Epsteins anomaly

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Simple teleconferencing equipment used in Belgrade
Standard video recorder/player for echo
examinations
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Conclusions

• This clinical service based on ISDN-2 technology,
  
• successfully uses simple, inexpensive equipment
  in Belgrade to link to more expensive existing
  equipment in London for Paediatric Cardiology
  Specialist advice
• enables patients in Serbia to obtain additional
  specialist advice which is unavailable in their
  own country

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Conclusion

• Expert advice on Paediatric Cardiology can be
  provided by the transmission of echocardiograms,
  radiographs and ECGs using ISDN-2 technology at
  128 kb/s

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Belgrade study was possible because

• BNU loaned ISDN-2 equipment to Belgrade
• BNU had a student from Belgrade who spoke both
  languages and could act as a co-ordinator
• Belgrade Paediatric Cardiology Consultant had
  worked at RBH
• Consultant at RBH was willing to give his time
  advice
• RBH had a telemedicine co-ordinator to organise
  teleconsultations

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Plans for the future

• To continue this clinical service
• To extend the service to include other
  specialties
• To extend the ISDN-2 system to allow MC to
  provide specialist advice within Serbia

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• For further details please email
• gwyn.weatherburn_at_bucks.ac.uk