Andersons pediatric cardiology 2311
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OutpatientTelecardiology
Severalgroupshavereportedimprovedaccessandqualitywithreducedcostsfor
bothadultandpediatriccardiologyoutpatientevaluations.58–60Suchsystems
aimtoreplicatetheclassicconsultationforremoteproviders,therebyextending
thereachofthespecialistintounderservedareas.Mostoftheseprogramsare
focusedonhistoryandtest(electrocardiogram[ECG]andechocardiogram)
review.Theseprogramsreducetheneedforface-to-faceevaluationsbutcan
increasetheoverallnumberofcontactswiththespecialist,likelyduetoready
specialistaccessforprimarycareproviders.61OneSpanishsynchronous
provider-to-providerconsultationwithmultimediasupporthadsimilarsuccess
whereonly10%ofpatientsundergoingteleconsultationrequiredtraveltothe
tertiary-carefacility.62
InCanada,synchronousteleconsultationhasbeenusefulforremote
preproceduralcounselingaswellasevaluationofnewpatientswithsyncopeand
supraventriculartachycardia.63IntheUnitedKingdom,abroadrangeofboth
inpatientandoutpatienttelecardiologyservicesareavailabletothedistrict
hospitals,utilizingvarioustechnologies.64–66Theirapproachimprovedaccess,
wascostneutral,andwasappreciatedbypatients.67Theauthorsstressedthat
thisapproachsupplemented,butwouldnotreplace,regularlyscheduledoutreach
clinics.Successfulsiteshaddedicatedclinicalchampionsandweredesignedby
localclinicianstomeettheirspecificneeds.Failingtorecognizethese
requirementshascausedotherstofail.68
Tele-auscultationcanalsobeapartofremoteconsultation,butisnotusedas
frequentlyasothermodalities,inpartduetocostandreimbursementissues.
Overthelast2decades,severalinvestigatorshaveevaluateddifferenthardware
andsoftwaresolutionsforremotemurmurevaluation.Belmontandcolleagues
utilizedthesynchronousapproachusingbothdigitalandanalogsystems.69,70
Theyfoundsignificantdifferencesinheartsoundcharacterizationwhen
comparedtoface-to-faceevaluationbyapediatriccardiologistusingananalog
stethoscope.However,whenusedtoclassifyoverallfindingsaseither
normal/innocentversuspathologic,theirtele-auscultationwasnodifferentthan
face-to-faceevaluation.
McConnelletal.alsoutilizedasynchronoustele-auscultationapproachwith
similaraccuracy.71
Otherinvestigatorshavefocusedontheasynchronous(store-and-forward)
tele-auscultationapproach;thatis,tohaveheartsoundsrecordedatthepatient
sitefortransmissiontotheremotecardiologistforlaterreview.72–74These
studieshavecombinedavarietyofdigitalrecordingstethoscopeswithelectronic
transmissionviae-mailoraweb-basedplatform.Overallaccuracywassimilarto
face-to-faceevaluation.75,76
Digitallyrecordedheartsoundsalsoprovidetheopportunityforcomputerized
analysisofthisphysiologicdata,referredtoascomputer-aidedauscultation
(CAA),andcouldbeincorporatedintoanasynchronoustele-auscultation
program.Severalgroupshaveappliedavarietyofsignalprocessingtechniques
topediatricheartsoundrecordingsandreportsensitivityandspecificityvalues
approaching100%.77–81Despitethepotential,CAAhasnotyetbeenwidely
adopteddespiteatleastoneFDA-approvedsystemcurrentlyavailable.Aswith
tele-auscultation,thisislikelyduetoacombinationoftechnical,practical,and
financialdisincentives.82
DirecttoConsumerTelemedicine
Themarketingofanddemandfor“directtoconsumer”medicalcareinthehome
viaweb-basedapplicationsthatincludetabletandsmartphoneapplicationsis
growingrapidly.83Manyinsuranceprovidersandlargeemployeehealthplans
areadoptingthistechnologyasawaytoprovidelowercostcareforcommon
problemsthatmightotherwiseresultinanemergencyroomvisit.84Directto
consumertelemedicineprimarilyreliesonvideoandaudioconnectionsbetween
physician(orotherhealthcareproviders)andthepatient.Thetablet,smart
phone,orcomputer-basedapplicationmayincludeadditionalfeaturesthatallow
forscheduling,billing,sharingofstill-frameimages,anddocumentation.In
somemodels,peripheralsmaybeavailablesuchassmartphones,compatible
heartrhythmdetectiondevices,85andotoscopes.86Inourprogram,weare
utilizingourownphysicianstoprovidethisserviceforfollow-upvisitsfor
syncope,preventivecardiology(obesityandhypercholesterolemia),
neurodevelopmentalassessment,andtransplant/chronicheartfailure.
Themostcommonmodelfordirecttoconsumertelemedicineisaoneofa
turn-keyservicethatincludesaccesstotechnologyandaphysiciangroup
providedthroughthesamevendorthatprovidesthetechnology.Thiscould,in
theory,createathreattothedeliveryofhighqualitycare,especiallyforcomplex
pediatricpatients.Additionally,astheuseofthesedevicesgrows,careful
attentionmustbepaidtopatientsafetyandprivacy.Inresponsetothisconcern
theAmericanTelemedicineAssociationhasimplementedanAccreditation
Programfortheprovisionofconsumer-directedtelehealthservices.87
