Telemedicine for Paediatric
Cardiology:
practical experience using
ISDN-6 & ISDN-2 technology
Gwyn Weatherburn
Reader in Medical Imaging
Research Centre for Health Studies
Buckinghamshire New University
&
Mike Rigby
Consultant Paediatric Cardiologist
Royal Brompton Hospitals NHS Trust
Dejan Mijin
Research student, BNU
Jovan Kosutic
Paediatric Cardiologist,
Mother & Child Institute, Belgrade
Tom Carter
Telemedicine Co-ordinator
Royal Brompton Hospitals NHS Trust
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)
ISDN-6 or ISDN-2?
How many lines are needed for
paediatric cardiology?
Royal Brompton’s 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
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)
Typical ISDN-6 teleconference equipment
3x ISDN-2 connections
Object camera
to show x-rays etc
Video recorder/player
for echo examinations
ISDN-6 codec and monitor(s)
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?
RBH and Belgrade study using
ISDN-2 technology
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
Equipment
At Royal Brompton (RBH),London:
• ISDN-6 existing teleconferencing
technology was used
At Mother &Child Institute (M&C), Belgrade:
• an ISDN-2 line was installed
• an ISDN-2 videophone was loaned
by BNU
WIRING REQUIREMENTS
RBH
ISDN-6
Belgrade
ISDN-2
RBH ISDN-6
Belgrade ISDN-2
Viewing equipment for radiographs, ECGs etc
RBH Object camera
Belgrade Standard viewing box
The teleconferences
Live discussions between clinicians
without patients present commenced in
December 2003
Transmission and discussion of :
• recorded echocardiograms,
• radiographs,
• ECGs
Ultrasound examinations
• Pre-recorded cross sectional
echocardiograms as routinely used by
paediatric cardiologists, conventional
• Subcostal,
• Apical parasternal,
• Suprasternal images
Results
• To September 9th 2004, there were
6 consultations during which,
• 17 patients were discussed
Results
• Picture & sound quality was usually good
• Connection time was short (< 1 min)
• Mean discussion time for each patient was
about 15 mins
Results
Yes
No
Echo viewed
14
2
ECG viewed
8
8
Xrays viewed
11
5
NB. Data missing for one patient
Effect of teleconsultation on diagnosis
1 7 child ren
1 1 m a le
6 fem a le
a g e ra ng e : 1 we e k to 17 ye a rs
D ia gn o sis ch an g ed
3 pa tien ts
D ia gn o sis u nch an g ed
1 4 pa tie n ts
Management changes after teleconsultation
17 patients
Management
change (11)
Different
surgery (4)
More invasive
treatment (6)
No previous
plan (2)
Refer to
other Specialist
at RBH (1)
Surgery at RBH
where device
available (1)
Management
unchanged (6)
Less invasive
treatment (3)
No surgery (2)
No action
at present (1)
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
Epstein’s anomaly
Simple teleconferencing equipment used in Belgrade
Single
ISDN-2
connection
Standard video
recorder/player
for echo
examinations
ISDN-2 videophone & standard film viewing box
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
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
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
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
M&C to provide specialist advice within
Serbia
For further details please email
[email protected]
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Telemedicine for Paediatric Cardiology: practical