Andersons pediatric cardiology 2314
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ofpediatriccardiologysystemsintoasingletelemedicinesystemandcorporate
partner,aunifieddatacollectionprotocol,andasharedmodelofdataaccess.117
TheNationalPediatricCardiologyQualityImprovementCollaborative(NPCQIC)hasfocusedonreductionofinterstagemorbidityandmortalityforsingle
ventriclepatientsafterstageIpalliation.118–122Thisprogramincludeshome
surveillanceofpulseoximetry,weight,nutritionalintake,andwarningsignsof
deterioration.115,123,124OneoftheconsistentfindingsfromtheNPC-QICisthe
importanceofweightgainonpositiveoutcomes.Thisisconsistentwithareport
byGhanayemetal.fromChildren'sHospitalofWisconsin,thatinitiationofa
programthatrecordeddailyweightandoxygensaturationathomeimproved
survivalinpatientswithhypoplasticleftheart115andplayedacriticalrolein
determiningtheidealtimingofbidirectionalGlenn.125Crossetal.reported
utilizationofatelemedicinesolutionforinterstagesingleventriclecarethat
incorporatedautomatedtransmissionofpulseoximetry,weight,andformula
intake,alongwithansweringquestionsaboutthestatusoftheinfant.126This
solutionincludedawebsitewithautomatedwarningalertsandapatient
dashboardforeasyaccesstosubtlechangesovertime.Theweight-for-age
percentileforpatientswithaccesstohometelemedicinewasmorelikelyto
increasethaninthosepatientswithoutaccesstohometelemedicine.
Take,forexample,patientW.L.,whowasbornwithhypoplasticleftheart
syndromeandunderwentstageIpalliationwithNorwoodreconstructionofthe
aorticarchandrightmodifiedBlalock-Taussigshunt.Hispostoperativerecovery
wasmostlyuneventfulandhewasdischargedhomearound3weeksofage.A
monthlaterheappearedtobelessplayfulthanusualbutnootherconcerns.Even
thoughtheylivedabout200milesaway,thefamilyknewthattheycouldhave
instantaccesstopediatriccardiologyservicesthroughthehospital-provided
tabletcomputer.Theytooka30-secondvideooftheirson'sbreathingand
obtainedheartrateandpulseoximetrynumbers,whichwerethenquickly
transmittedtoacloud-basedserver.Hisheartcenterstaffgotaninstantpager
notification.Theyastutelynotedsubtleincreaseinrateandworkofbreathing
andarrangedforhospitaladmission.Anechocardiogramintheemergencyroom
confirmeddevelopmentofcoarctationofthereconstructedaorticarch,which
wastreatedwithballoonangioplastyandresultedinsymptomaticreliefand
possiblepreventionofdeath.
GlobalTelemedicine
Lessthan10%oftheworld'spopulationhasaccesstolife-savingsurgicaland
catheter-basedinterventionstotreatevenlow-riskcongenitalheartdefects,127
andrheumaticheartdiseaseremainsendemicacrossmostoftheglobe.128
Collaborationbetweencardiologyandcardiacsurgeryexpertsinhigh-income
countriesandprogramsinlow-andlowermiddle-incomecountriesisessential
toclosethisgapincare.Telemedicinecanbeaverypowerfultooltofacilitate
careanddiseasepreventioninlow-andmiddle-incomecountries.129Educational
webconferencescanhaveasignificantimpactonimprovingoutcomesfor
congenitalheartsurgeryinresource-poorcountries.130Livepatientcare
conferencesandsharingofimagesviacloudimagingcanadvanceresearch
collaborationforcongenitalandrheumaticheartdisease.131,132Werecently
reportedonusingtelemedicinetofacilitatescreeningofover4000Brazilian
childrenforrheumaticheartdisease.133Echocardiogramsperformedinschools
inBrazilwereuploadedtothecloudandinterpretedjointlybyphysiciansin
BeloHorizonte,Brazil,andWashington,DC.Thereare,however,several
challengestosuccessfulimplementationofglobaltelemedicineprograms.These
includedifferencesintimezone,language,culture,localgovernment
regulations,Internetsecurity,maintenanceofequipment,andlackofaccessto
affordablebroadbandconnectivity,especiallyinmoreremoteregions.
CloudComputing
Cloudcomputingandtelemedicineexpertiseisnowalsocommerciallyavailable.
Insteadofon-sitedatastorage,vendorslikeGEViosWorksprovidecloud
computing,flexiblestorage,andcompleteanalysisservicesonapay-per-use
basis.Usingthisapproach,thehospitalscansaveonhumanresources,and
purchaseandmaintenanceofspecializedsoftwareforcardiovascularimage
analysis,suchastoassessmyocardialironoverload,MRIfour-dimensional
(4D),flow,andfractionalflowreserve.Vendorsensurepatientprivacyanddata
securitybyworkingwithdeidentifieddatawhiletheidentifiersstayatthesource
hospital.Cardiovascularimagingexpertsaresayingthatifpatientprivacyand
datasecurityareguaranteed,cloud-basedexperttelemedicinecareisavaluable
option,especiallytooffersophisticatedcardiovascularimageanalysissuchas
computationalfluiddynamicmodelingand4Dflowforallinstitutions.134There
ismountingliteratureonthisformoftelemedicinesuggestingthatimagedata
canbeobtainedinafractionofthetimewhenusingcloud-baseddistributed
computingreconstruction.Crossetal.reported37%reductioninacquisitionand
reconstructiontimeforMRIventriculometry.135Cheluandcolleagues,using4D
flowimagingpostprocessedwithanintegratedcloud-basedapplication,
accuratelyquantifiedpulmonaryflowwhencomparedtotraditionalphase
contrastflowmeasurements.136Toleveragecloud-basedtelemedicine,the
Gadgetronisanopen-sourceframeworkformedicalimagereconstructionthat
hasbeendevelopedattheNationalHeart,Lung,andBloodInstituteandatthe
DepartmentofComputerScienceandDepartmentofClinicalMedicine,Aarhus
University,Denmark.137Itismadefreelyavailabletothemedicalimage
reconstructioncommunity.Itisforeseeablethatinstitutionswillutilize
Gadgetron-liketoolstoprovidecloud-basedtelemedicineinascalablewayto
improveimagereconstructionandquantificationofdata.
Timeandexpertiseareextremelyvaluableresourceswithinthehealthcare
industry,ascareprovidersareonaconstantruntoservetheirpatientsefficiently.
Telemedicineoutsourcingofcareandserviceprovidersisnonewphenomenon
topediatriccardiology.However,clouddeliveryofmedicaldatahasevolvedto
bethemosteconomicandeffectivesolution.Withallthetelemedicineservices,
legacyapplications,obsoletetechnologyprotocols,andinfluxofsmartInternet
ofthingsdeviceswithinthehospital,ransomwarethreathasbecomeareality
