People that live in rural areas wait for the care that they need with no guarantee of their futures: this is just the way things have been. But can telecardiology help rural patients? The United States is filled with rural land areas where 72% of the United States’ land area belongs to rural counties. In 2014 it was estimated that 46.2 million Americans lived in these rural areas. Health disparities do exist between rural and urban United States.
“We view telemedicine as an important tool in increasing consumer access to high quality, affordable healthcare, improving patient satisfaction and reducing cost. Given recent advances in technology, telemedicine gives customers a new way to be more engaged in their care, and save time and money. Additionally, telemedicine contributes to the value-based care goals of patient engagement, expanded hours for primary care, population health management and care coordination,” – Representatives from eleven private insurers, including Aetna, Humana and Anthem, in a public letter to Congressional Budget Office director Keith Hall.
Rural Americans are more likely to suffer from chronic health conditions such as diabetes, heart disease, and cancer.
What is Telemedicine and Telecardiology?
Telecardiology is the application of telemedicine in the field of cardiology. Telemedicine is the delivery of healthcare and sharing of medical knowledge by using information technology (IT).
One of the reasons this is so powerful is that providers can work almost as a unit while being in different geographical locations for e-consults, examinations, and medical procedures.
Among all clinical disciplines, the widest use of telemedicine in the twentieth century has been in cardiology. Why?
Mainly this was due to the necessity of urgent diagnosis of the cardiovascular system. Telemetry of “electrocardiosignals” (ECG/EKG) for remote interpretation matched the technical capabilities of electrical engineering in the last century.
Most researchers consider March 22, 1905, as the birthday of telemedicine. Wilhelm Einthoven professor of Leiden University transmitted a regular electrocardiogram and “phonocardiogrammes” via a protected telephone cable at a distance of about 1500 meters from the University Hospital laboratory at W. Einthoven’s house.
We now have the cloud which will take us into a new era in the field of telecardiology.
Applications of in diagnosis and management are numerous yet, here are a few to begin with: hypertension, implantable electronic devices, echocardiography and coronary CT scans, reduction of sudden cardiac death, diagnosis and treatment of arrhythmias and the list goes on.
Applications of in diagnosis and management are numerous yet, here are a few to begin with: hypertension, implantable electronic devices, echocardiography and coronary CT scans, reduction of sudden cardiac death, diagnosis, and treatment of arrhythmias and the list goes on.
Telecardiology has been around for quite some time now. It uses telecommunication methods for diagnosis, treatment, and care of the patients with heart disease. Early application of the telecardiology involved the transfer of EKGs via fax and consultation with specialists by telephone. Recently, things have shifted with use cases of telecardiology in areas like remote patient monitoring, EKG, echocardiograms, teleconsultation through video, monitoring and rapid interpretation cardiac diagnostic tests and teleconferencing for interventional cardiology.
Rural areas are already short of medical professionals and specialist care is hard to find. We’ll focus on how we can harness technology applied in ways that can make healthcare accessible to rural Americans.
Heart Disease: How Prevalent is the Problem?
Heart disease refers to heart ailments such as heart attack, arrhythmia, and heart valve problems, and is included in a more broad set of cardiovascular diseases, such as stroke and acute rheumatic fever.
The U.S. has seen significant improvements in both mortality and disease burden due to heart disease over the past few decades, as well as more recent improvement in some indicators of quality of care for heart disease. Heart disease has long been the leading cause of death in the U.S. and currently remains so, accounting for 23.4% of all deaths in 2015 – slightly more than malignant neoplasms (cancer), which accounted for 22% of all deaths. Stroke is the fifth leading cause of death, accounting for 5.2% of all deaths in 2015.
Heart disease has long been the leading cause of death in the U.S. and currently remains so, accounting for 23.4% of all deaths in 2015 – slightly more than malignant neoplasms (cancer), which accounted for 22% of all deaths. Stroke is the fifth leading cause of death, accounting for 5.2% of all deaths in 2015.
Some types of heart disease are progressive without overt signs and symptoms. Timely diagnosis and early intervention are keys to treatment and saving lives.
There are many cardiology patients there yet, no cardiologist attending patients in rural settings. Patients may travel to a larger city for care. For some, this means turning to the internet to research and find medical treatments. Every American should have access to high-quality care. In this article, we’ll look at approaches that are being implemented to close the gap in cardiac care between urban and rural healthcare settings.
Telecardiology can start with selected presentations like primary cardiological care (blood lipid control, high blood pressure management, heart attack treatment and follow-up) and non-invasive diagnosis and treatment (chronic heart failure, echocardiography, EKG, and monitoring hear functioning).
The conception of telecardiology is feasible to the application of the telecardiology in rural areas.
What Has Been Done Elsewhere Like India?
Not unlike rural communities here in the U.S., rural communities in India lack basic access to cardiac care. One study published in the Indian Journal of Community Medicine examined the feasibility of a telecardiology system. Five rural clinics were linked to a teaching hospital. Inexpensive cardiographs and tablets were used to transmit ECGs to the teaching hospital for interpretation. ECGs were acquired on 380 patients at the clinics. Cardiologists found 86 ECGs (22.6%) with abnormal findings.
Uses of telecardiology
ECG is a necessary diagnostic tool in diagnosing and managing ischemic heart disease and arrhythmias. Most primary care settings have an EKG. Access to specialists reading EKGs can assist with early referrals to secondary care and reduce unnecessary referrals to cardiologists.
There are many applications for the use of telecardiology and here are a few applications to investigate further:
- community screening for accurate atrial fibrillation diagnosis
- Screening for patients suspected of having heart failure
- Mobile technology and the digitization of healthcare
- rapid cardiological assessment to prevent unnecessary admissions
- Ubiquitous wireless ECG recording: a powerful tool physicians should embrace
- decreasing door-to-balloon time in patients with ST-segment elevation MI
- cardiology re-reads as a managed service
- remote prehospital diagnoses in patients suspected of acute myocardial infarction
- prompt diagnosis in ECG for primary care
- on-demand cardiology video visits or imaging interpretations
- image interpretations to allow hospital cardiologists more direct patient contact and improved allocation of resources
- cardiology hospital support and resource allocation for weekends or evening coverage
- access to specialists in rural areas
- remote patient monitoring
For primary care providers getting an accurate ECG report from a specialist can be a challenge. Primary care providers have varying levels of abilities required to interpret ECGs. One study determined that primary care professionals were unable to diagnose atrial fibrillation. A lack of reliable ECG testing, interpretation and reporting can lead to cardiac conditions being missed.
Patients with acute coronary syndrome typically present to secondary care but some may present to a primary care provider. In these cases, ECG testing is the clinical standard and a reliable interpretation may give more insights into the diagnosis but, also the need for an urgent referral. The management of cardiac disease with the use of ECG can detect changes such as atrial fibrillation or left ventricular hypertrophy in high-risk individuals with conditions like hypertension and dyslipidemia. Other groups that are more prone to coronary artery disease like diabetics or patients with chronic kidney disease can benefit from early detection of silent myocardial ischemia.
In all, telecardiology provides diagnostic support for primary care practitioners that allows them to manage more of their own patients while increasing capacity. Telecardiology can empower primary care providers but also allow for a complete clinical assessment for cardiac patients.
Many patients present to the emergency room with symptoms of acute coronary syndrome (ACS) and less than 50% of these patients actually have acute coronary syndrome.
Klinkman et al. showed that 75% of all analyzed chronic chest pain referrals from primary care to cardiologists were due to non-cardiac causes, musculoskeletal or non-specific in origin. Guidelines do dictate that patients suspected of acute coronary syndrome and current chest pain must be referred on to emergency secondary care even in the presence of a normal ECG.
ECG represents a part of the clinical assessment of chest pain but not the whole and clinical expertise is required to make a proper assessment.
There is evidence to suggest that the use of a telecardiology service can reduce the number of unnecessary hospital referrals and admissions. In 2002, a study by Molinari et al. looked at 100 GPs over the course of one month. One hundred and thirty-four out of 456 patients presenting with cardiac-type symptoms were suspected to have genuine coronary events. However, through the use of a telecardiology service, it was confidently demonstrated that 84 out of the 134 patients with suspected coronary events had no ECG abnormalities whatsoever.
As such, unnecessary hospitalization was avoided. Based on an average hospital stay of three days per patient, and a daily hospitalization cost of $2000 per patient, the service was estimated to have saved $504,000.
Accepting that the ECG represents only part of the clinical assessment of chest pain, these results demonstrate telecardiology’s potential to reduce costs.
Reduced Missed Diagnoses
In the study mentioned above, investigators found that out of 322 patients deemed not to have had an acute coronary event, 56 patients (17%) were actually found to have had one following subsequent ECG testing and a teleconsultation with a cardiologist. Thirty-eight of these 56 patients were subsequently diagnosed with an acute coronary syndrome.
As far as the detection and monitoring of chronic heart disease is concerned, and as already mentioned, there are many groups of patients who would benefit from opportunistic 12-lead ECGs. In terms of arrhythmia detection, in particular, the 1-lead ECG watch holds enormous potential through its novel design. These devices enable the patient to activate cardiac monitoring as and when they feel unwell. This is unlike the current 24-hour Holter tape method, the application of which might not coincide with the next bout of arrhythmia. Indeed, there is evidence to suggest that this method is superior, as a study found that hand-held event recorders picked up arrhythmias in 70% of the patients assessed, compared to 35% in the Holter-monitored cohort.
Monitoring patients in this way can improve the detection of suspected arrhythmias. It can also monitor arrhythmias after the commencement of medical treatment or post-atrial fibrillation ablation.
Door to Balloon Time
For the minority of patients presenting to their primary care rather than to the ER or to paramedics, telecardiology plays a significant role in allowing the timely diagnosis of ST-segment elevation myocardial infarction (STEMI) prior to hospitalization.
This is of critical importance, as a pre-hospital diagnosis of a STEMI reduces door-to-balloon time. One study published in the American Journal of Cardiology demonstrated that the pre-hospital ECG was ‘the single most important factor’ in reducing door-to-balloon time.
Reducing door-to-balloon time greatly decreases patient mortality.
Terkelsen et al. demonstrated that a pre-hospital diagnosis of STEMI via telecardiology reduced door-to-balloon time to 38 minutes, as opposed to 81 minutes for those without a pre-hospital diagnosis.
Convenience of Telemedicine
Telecardiology devices are small, mobile and usually operated by a single button. Devices can be moved easily from room to room within a practice and can be taken out into the community. They can support the service of those primary care providers on-call and would prove indispensable to those practicing in remote areas.
From a patient’s perspective, it is also more convenient and comfortable to undergo ECG testing in one’s own home or local primary care office-practice, as opposed to in a hospital.
These devices allow for a more convenient approach to heart disease yet, barriers and challenges in implementing telecardiology.
For instance, rural communities suffer from a lack of broadband infrastructure.
Although there is a clear benefit of remote consultation by video conference and imaging interpretation for rural patients, the technological infrastructure must be available to support these services.
Reimbursements are still a problem due to variations in laws from state to state.
Bring it Together: Rural Telecardiology With Mobile, Cloud and Data Storage
Cloud computing and mobile computing together can improve storage, delivery, retrieval and management of medical files. Big data also plays a pivotal role in this field and we can optimize care based on the data analysis. IT and telecardiology work well together and they always have yet, there are a few issues that should be addressed:
- Data confidentiality in the cloud
- Data interoperability among hospitals
- Network latency and accessibility
Telecardiology allows the provider to monitor or diagnose a patients heart activity across time and space.
Wireless communication permits fewer interruption errors compared to a traditional phone line. Mobile and cloud computing in 12-lead ECG and ECHO telecardiology are the current technological development in telecardiology. We can improve in these areas:
- Improve the current instruments and the software so that qualified cardiologists can remotely access files and offer timely assessments and treatment recommendations when he or she is distant from the patient.
- Make telecardiology services interoperable across hospital
- Set up a cost-effective platform that incorporates clinical services, clinical research data, and educational services.
- Set up a cost-effective platform that incorporates clinical services, clinical research data, auditing and educational services for patients and staff.
An ECG is a waveform based tool and ECHO or echocardiogram is an image based tool that allows the evaluation of cardiac and vascular anatomical structures and physiological functions.
One of the most promising advantages of telecardiology is that it will allow remote cardiologists to conduct timely diagnostics and propose effective strategies for patients located in rural areas. Not only can patients receive medical intervention but outcomes can be improved like lowered mortality rates, reduce costly transport from home to hospital or the prevention of unnecessary transfers as previously mentioned.
ECG telemedicine has three categories: pre-hospital, post-hospital and in-hospital. New developments allow users to merge these categories into a continuum. Lack of access to providers, insufficient resources at home like caregivers, financial status etc. can lead to lapses in treatment causing readmissions and unnecessary visits, in turn, driving up costs.
Despite positive results from many individual studies, telecardiology needs to be subjected to the kind of meta-analyses normally employed to assess the effectiveness of any medical intervention.
Telecardiology, by bringing expert clinical and imaging expertise has the potential to save time, money and lives. It empowers providers and patients, providing a robust diagnostic tool to facilitate the management of cardiac patients in the rural community. Both physicians and patients benefit in terms of ease of access, the speed of diagnosis, the efficiency of management and the freeing up of resources. There remains a need for further large randomized controlled trials and cost-efficacy data to evaluate these findings on a wider scale. In conclusion, telecardiology has the potential to revolutionize the way various heart conditions are managed in the primary care setting.
Telecardiology is here to stay and may represent a step change for the use of further clinical tools that harness information technology to augment patient care.