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 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

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 Echo viewed ECG viewed 14 8 No 2 8

Xrays viewed

11

NB. Data missing for one patient

Effect of teleconsultation on diagnosis

17 children 11 male 6 female age range: 1 week to 17 years

Diagnosis changed 3 patients

Diagnosis unchanged 14 patients

Management changes after teleconsultation

17 patients

Management change (11)

Management unchanged (6)

More invasive treatment (6)

No previous plan (2)

Less invasive treatment (3)

Different surgery (4)

Refer to other Specialist at RBH (1)

Surgery at RBH where device available (1)

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 Epsteins 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 gwyn.weatherburn@bucks.ac.uk