Telemedicine in Pediatric Cardiology

Telemedicine now pervades almost every aspect of the practice of pediatric cardiology. Simply defined, telemedicine means using technology to practice medicine at a distance–and it is now used on a daily basis for clinical care, education, research, and administrative tasks. Use of the cloud to transfer images (echocardiogram, angiography, computed tomography [CT], or magnetic resonance imaging [MRI]), remote attendance at patient care conferences, home monitoring of interstage single-ventricle patients, wearable devices for rhythm detection, and remote login to view monitor tracings for intensive care unit patients are all examples of telemedicine. This technology is now accessible on smart phones and tablets, and most users could not imagine practicing medicine without it. This chapter provides an overview of how tele-echocardiography and other modalities of telemedicine are used in pediatric cardiology, with a focus on how technology and clinical use have evolved.


Telemedicine has become the standard of care in pediatric echocardiography. Tele-echocardiography can be carried out via live videoconference in real time or as store-and-forward images to be viewed remotely. Initial telemedicine studies utilized point-to-point Integrated Services Digital Network (ISDN) and Terrestrial-1 connections for live telemedicine with good image quality and acceptable temporal resolution (frame rates of 23 to 30/second). Rapid progression of technology over the last 10 years has made this technology obsolete. Today, Internet Protocol (IP) allows for multipoint network connectivity that enables use of codecs or videoconferencing software from anywhere on any device. These include room systems, desktop or laptop computers, tablets, and smart phones.

The field of pediatric tele-echocardiography has predominantly evolved into store-and-forward solutions that, in many cases, are extensions of existing echocardiography picture archiving and communication systems (PACs) with special considerations for data transfer. Direct point-to-point study transmission options include secure file transfer protocol (FTP) and virtual private network (VPN). Cloud servers enable transmission of and access to echocardiograms from anywhere in the world with subsequent download into local PACs servers. Many physicians access echocardiograms via remote connection to PACs networks through client or web-based programs. In our hospitals, we have a mix of all of these technologies, but we prefer that studies be transferred into our PACs system for uniform interpretation and reporting. However, some partner hospitals insist on us reporting in their local PACs and electronic medical records. Diligent attention to security, licensure, and credentialing requirements, and compliance issues as well as a need for 24/7 technical support staff are critical for maintenance of a successful tele-echocardiography network.

Multiple studies have found neonatal tele-echocardiography to be accurate and cost-effective, have a positive impact on patient care, prevent unnecessary transports, and improve sonographer proficiency. Table 91.1 , modified from a recent scientific statement from the American Heart Association, provides a summary of several of these studies. When not diagnosed prenatally, newborns with congenital heart disease are often delivered, or present to a primary care setting, where expert cardiovascular evaluation may not be available. Management decisions based on incomplete or delayed diagnostic information may result in morbidity and mortality or unnecessary transfers. Randolph et al. reported that using telemedicine resulted in a complete diagnosis for 132 of 133 patients (99%) with suspected congenital heart disease. Patient transfer was recommended or avoided in seven patients, an immediate change in local medical management occurred in an additional 25 of 133 neonatal patients (19%), and congenital heart disease not requiring immediate treatment was noted in 47 infants (35%).

Table 91.1
History of Pediatric/Congenital Tele-Echocardiography Publications
From Satou GM, Rheuban K, Alverson D, et al. Telemedicine in pediatric cardiology: a scientific statement from the American Heart Association. Circulation. 2017;135(11):e648–e748.
Study Location Year(s) Key Findings
Finley Nova Scotia 1989, 1997, 2004 Real time over POTS, cost savings, tele-education
Sobczyk Kentucky 1993 Store and forward over POTS
Fisher Chicago 1996 Real time over single ISDN line
Casey Ireland 1996, 1998, 2008 Real time over low bandwidth connection
Rendina North Carolina 1997, 1998 Outcomes and reduced length of stay
Houston Glasgow 1999 100% accuracy requires 3 ISDN lines
Randolph Minnesota 1999 Accuracy, management over T1
Sable New Orleans 1999 Accuracy, proficiency, cost savings over 3 ISDN lines
Scholz Iowa 1999, 2001 Minimal difference: cardiologist vs. pediatrician ordering echo in children less than one year of age
Sable Washington, DC 2002 500 studies/3 ISDN lines/impact on practice
Sharma New York 2003 Efficacy of fetal tele-echocardiography
Widmer Switzerland 2003 Real time over 3 ISDN lines/feasibility and accuracy
Munir Hawaii 2004 Live and store and forward between Hawaii and Guam
Sahn Portland 2004 Remote real time image control and optimization
Woodson Washington, DC 2004 Forward and store tele-echocardiography
Castela Portugal 2005 1761 consultations over 5 years/mostly elective
Lewin Seattle 2006 769 studies/3 ISDN lines/99% accurate
Awadallah South Dakota 2006 Neonatal tele-echocardiography triage
Sekar India 2007 Real time/small aperture satellite bandwidth
Koustic London 2007 Belgrade to London conference over single ISDN line
Gomes Portugal 2010 Fetal, neonatal, and pediatric consultations in real time
McCrossan Ireland 2011, 2012 Fetal tele-echo accuracy and skill transfer
Haley Arizona 2012 Real time telemedicine more accurate than recorded echocardiograms
Dehghani Canada 2013 Videoconferencing for ACHD management
Webb US (9 sites) 2013 Multicenter prospective case-control study: tele-echo decreases transports, length of stay, and high-risk medications
Krishan Washington, DC 2014 Technology transition, >10,000 studies/15 years
ACHD, Adult with congenital heart disease; ISDN, integrated services digital network; POTS, plain old telephone systems; T1, Terrestrial 1.

Rendina et al. reported a reduction in length of stay of 5.4 days in a level III North Carolina neonatal intensive care unit in the first 6 months of their study compared to the 6 months prior without telemedicine. The cost attributable to telemedicine in their model was $33 per echocardiogram. They projected that cost savings over a 1-year period would be $1.3 million. Additional monetary benefits of telemedicine that are more difficult to quantify include cost savings from prevention of delayed or incorrect management, and avoidance of the financial burden of travel and lost wages for the patient's family. In a study of 500 echocardiograms in the Washington, DC, metro area, comparison of final videotape interpretation to initial telemedicine diagnosis resulted in only one minor diagnostic change (membranous vs. inlet ventricular septal defect), and telemedicine had an immediate impact on patient care in 151 studies.

We reported on our technology transition experience of over 10,000 telemedicine transmissions from 24 sites in seven states and territories between 1998 and 2014. A significant increase in telecardiology utilization took place after IP expansion without detrimental effects on efficiency or diagnostic accuracy. This occurred in parallel to a change from a predominance of real-time telemedicine to store and forward transmissions. Over 150 patients were transported for surgical, catheter-based, or medical intervention, and critical heart disease was ruled out in over 75 patients, preventing unnecessary transport. Medical management and/or outpatient follow-up was recommended in approximately half of the studies for minor heart defects.

A multicenter study from nine centers assessed the impact of telemedicine on infants with either no or minor heart disease. The authors identified 338 pairs of infants with and without access to telemedicine, and were matched for study indication, diagnosis, gestational age, birth weight, and gender. Access to telemedicine resulted in statistically significant reductions in rate of transfer to a tertiary care hospital (10% vs. 5%), total and intensive care unit length of stay, and inappropriate use of inotropic support and indomethacin ( Tables 91.2 and 91.3 ).

Table 91.2
Length of Stay From a Multicenter Study
From Webb CL, Waugh CL, Grigsby J, et al. Impact of telemedicine on hospital transport, length of stay, and medical outcomes in infants with suspected heart disease: a multicenter study. J Am Soc Echocardiogr. 2013;26(9):1090–1010.
Telemedicine Control P Value
Total length of stay 1.0 ± 6.8 days
Range: 0–102 days
2.6 ± 11 days
Range: 0–96 days
Length of ICU stay 0.96 ± 6.8 days
Range: 0–102 days
2.5 ± 11 days
Range: 0–96 days
Total length of stay 0.72 ± 4.1 days
Range: 0–44 days
1.6 ± 6.4 days
Range: 0–58 days
Length of ICU stay 0.65 ± 4.0 days
Range: 0–44 days
1.6 ± 6.2 days
Range: 0–58 days
ICU, Intensive care unit.

a Greater than 60 days.

Table 91.3
Medical Complications/Interventions From a Multicenter Study
From Webb CL, Waugh CL, Grigsby J, et al. Impact of telemedicine on hospital transport, length of stay, and medical outcomes in infants with suspected heart disease: a multicenter study. J Am Soc Echocardiogr. 2013;26(9):1090–1098.
Telemedicine Control P Value
Inotropic support 8% ( n = 27) 26% ( n = 88) <.001
Indomethacin a 11% ( n = 29) 18% ( n = 47) .026
Prostaglandin E 1 0% ( n = 0) <1% ( n = 1) NS
Mechanical ventilation 28% ( n = 94) 30% ( n = 101) NS
Extracorporeal membrane oxygenation 1% ( n = 2) <1% ( n = 1) NS
Intraventricular hemorrhage 7% ( n = 24) 5% ( n = 15) NS
Cardiac arrest 2% ( n = 6) 3% ( n = 11) NS
Death 4% ( n = 13) 4% ( n = 12) NS

a Indomethacin data only available on 268 matched pairs

Neonatal pulse oximetry screening for critical congenital heart disease is currently mandated in almost every state and is a driver for the establishment of telemedicine links between community hospitals and tertiary care pediatric cardiac centers. Telemedicine can provide timely access to pediatric subspecialists in cardiology and neonatology for assessment and treatment recommendations if a positive screen is obtained. There is an argument that false-positive pulse oximetry screens could increase the number of tele-echocardiograms, pushing up costs and overburdening pediatric cardiologists providing interpretation. However, a recent study shows that the additional increase in echocardiograms from pulse oximetry screening is negligible when compared to the number of false-positive echocardiograms generated by heart murmurs.

Fetal Telemedicine

Fetal telemedicine can increase prenatal detection of critical congenital heart disease. Sharma et al. reported that adequate screening for fetal heart disease is feasible and community acceptance for telemedicine-assisted fetal cardiac screening and counseling is not adversely affected by a lack of direct personal contact with a specialist. Prenatal detection of congenital heart disease has been shown to improve postnatal surgical and heart transplantation outcomes. Fetal telemedicine is also used across all links of the referral chain, from the primary obstetrician's office to the quaternary fetal health care facility. It is routinely performed by obstetricians, maternal-fetal medicine specialists, and pediatric cardiologists to screen for congenital heart disease and fetal arrhythmias. If pathology is suspected or detected, these providers can refer patients to a higher level of care. Because access to fetal cardiac expertise is limited for people in remote or rural locations, fetal tele-echocardiography can be especially helpful in these populations. The use of fetal ultrasound to detect congenital heart disease can also help pediatric cardiologists and maternal-fetal medicine specialists work together to prepare families for delivery and treatment options.

Fetal telemedicine can also be diagnostic for fetal arrhythmias. In the case of fetal bradycardia secondary to atrioventricular block, tertiary care fetal health centers can use fetal telemedicine to guide and monitor pharmacotherapy and delivery planning, which is paramount for patients that are likely to need an urgent pacemaker after birth. Fetal telemedicine can also play an important role in diagnosing and treating fetal tachycardia. Transplacental or direct fetal antiarrhythmia treatment, follow-up evaluations, and delivery plans can be appropriately determined upon review of the images. There are currently commercial and FDA-approved hand-held Doppler fetal heart rate monitors available for patient home use. Prospective parents can purchase them at low cost on the Internet. These devices hold promise, especially if they have Bluetooth or network connectivity. However, more data is needed to assess the utility of these devices for future home monitoring, The importance of physician input is critical, as inappropriate use of home monitoring can do more harm than good.

Intensive Care Unit/Cardiac Intensive Care Unit

Telemedicine has many applications in the pediatric intensive care unit, cardiac intensive care unit, and emergency department, using a broad range of applications to assist in the care of hospitalized children in a variety of clinical scenarios. There is increasing acceptance and evidence that providing pediatric critical care and telecardiology consultations to remote emergency departments for children with suspected or known cardiovascular disease is feasible and adds clinical value. Telemedicine can be used in an on-demand or continuous model for support of critical care patients. In the former model, physician consultations, nurse and physician monitoring, and medical oversight can be provided on an as-needed basis. A pediatric cardiologist or intensivist can evaluate and provide recommendations on diagnostic studies, medications, or other therapies. The other end of the spectrum integrates continuous oversight via monitoring and proactive medical decision making. All models require compliance with best critical care practices and maintenance of training, including advanced life support certifications and participation in quality assurance programs.

Use of telemedicine in a variety of critical care programs around the globe have demonstrated improvements in clinical outcomes, including length of stay and mortality and increased provider and parent satisfaction. Reductions in healthcare costs occur due to more appropriate transport utilization and decreased utilization of costlier tertiary intensive care unit beds. Patients in critical care settings with access to telemedicine can be more quickly evaluated, stabilized, and triaged to determine the need for transport and more advanced treatment. Munoz et al. reported on a telemedicine-supported cardiac intensive care unit collaboration between Pittsburgh and Bogota, Columbia. This program included a web interface of physiologic monitors and videoconferencing via a mobile telemedicine cart. Face-to-face videoconferencing, sharing of medical images, and review of rhythm disturbances resulted in 71 recommendations in 53 patients including management of arrhythmias and surgical and catheterization planning.

Outpatient Telecardiology

Several groups have reported improved access and quality with reduced costs for both adult and pediatric cardiology outpatient evaluations. Such systems aim to replicate the classic consultation for remote providers, thereby extending the reach of the specialist into underserved areas. Most of these programs are focused on history and test (electrocardiogram [ECG] and echocardiogram) review. These programs reduce the need for face-to-face evaluations but can increase the overall number of contacts with the specialist, likely due to ready specialist access for primary care providers. One Spanish synchronous provider-to-provider consultation with multimedia support had similar success where only 10% of patients undergoing teleconsultation required travel to the tertiary-care facility.

In Canada, synchronous teleconsultation has been useful for remote preprocedural counseling as well as evaluation of new patients with syncope and supraventricular tachycardia. In the United Kingdom, a broad range of both inpatient and outpatient telecardiology services are available to the district hospitals, utilizing various technologies. Their approach improved access, was cost neutral, and was appreciated by patients. The authors stressed that this approach supplemented, but would not replace, regularly scheduled outreach clinics. Successful sites had dedicated clinical champions and were designed by local clinicians to meet their specific needs. Failing to recognize these requirements has caused others to fail.

Tele-auscultation can also be a part of remote consultation, but is not used as frequently as other modalities, in part due to cost and reimbursement issues. Over the last 2 decades, several investigators have evaluated different hardware and software solutions for remote murmur evaluation. Belmont and colleagues utilized the synchronous approach using both digital and analog systems. They found significant differences in heart sound characterization when compared to face-to-face evaluation by a pediatric cardiologist using an analog stethoscope. However, when used to classify overall findings as either normal/innocent versus pathologic, their tele-auscultation was no different than face-to-face evaluation.

McConnell et al. also utilized a synchronous tele-auscultation approach with similar accuracy.

Other investigators have focused on the asynchronous (store-and-forward) tele-auscultation approach; that is, to have heart sounds recorded at the patient site for transmission to the remote cardiologist for later review. These studies have combined a variety of digital recording stethoscopes with electronic transmission via e-mail or a web-based platform. Overall accuracy was similar to face-to-face evaluation.

Digitally recorded heart sounds also provide the opportunity for computerized analysis of this physiologic data, referred to as computer-aided auscultation (CAA), and could be incorporated into an asynchronous tele-auscultation program. Several groups have applied a variety of signal processing techniques to pediatric heart sound recordings and report sensitivity and specificity values approaching 100%. Despite the potential, CAA has not yet been widely adopted despite at least one FDA-approved system currently available. As with tele-auscultation, this is likely due to a combination of technical, practical, and financial disincentives.

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