Remote imaging via FaceTime for potential long-distance diagnosis of suspected cardiac structural and shunt anomalies on contrast echocardiography (The RIFLE Study)
Jose Donato A. Magno M.D.,1 Romeo J. Santos M.D.,1 Edwin S. Tucay M.D.,1 Vianelly Berwyn F. Flores M.D.,1 Ronald E. Cuyco M.D.1
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Certain cardiac anomalies can be missed by standard transthoracic echocardiography and are usually confirmed through contrast echocardiography, a specialized procedure that warrants supervision by a cardiologist with advanced echo training. However, the maldistribution or lack of echo specialists in certain countries, especially in archipelagic settings, deprives many patients of such procedures and probably contributes to delayed diagnosis and treatment. We wanted to find out whether onsite interpretations of contrast echocardiograms of patients with suspected cardiac anomalies are comparable to offsite readings made via the real-time videoconferencing technology of FaceTime.
Agreement in echo readings was reported as overall agreement rate (% of congruent readings divided by total number of data points for comparison) and Kappa coefficient. The impact of contrast echocardiography on the final diagnosis at both sites was likewise assessed (accuracy rates for pre- and post-contrast diagnoses, with the official test report as reference standard). Video and audio quality were evaluated using a subjective scoring scale, while internet connection was assessed in terms of lag time to transmission (milliseconds), as well as download and upload speeds (Megabytes per second).
Sixty-eight (68) videoconferencing sessions were conducted on patients 37 ± 14 years (62% females). Overall reading agreement rate was 89% (1333 congruent readings out of 1496 data points), with most disagreements arising from chamber size evaluation (left ventricle, left atrium and coronary sinus dimensions). Good concordance (kappa > 0.60) was demonstrated between onsite and offsite readings in 14 of 22 parameters. Accuracy rates were comparable for precontrast onsite (51%) and offsite (54%) readings, with a substantial improvement in post-contrast readings (88% onsite and 79% offsite). Only 11 of 68 sessions (16%) had discordant final diagnoses, most of which consisted of overdiagnosis by the offsite reader. Video (3.6) and audio (3.8) quality scores were high (maximum of 4) for both sites, with acceptable lag time (PING < 250 ms), download (2.1 Mbps) and upload (0.3 Mbps) speeds.
Onsite interpretations of contrast echocardiograms are comparable to offsite readings made via real-time videoconferencing, with contrast echocardiography enhancing accuracy of diagnosis at both ends. Moreover, FaceTime was feasible, generating acceptable internet speeds as well as obtaining high audio and video quality scores at both ends of the transaction. These findings suggest a role for tele-echocardiography in long-distance, point-of-care diagnosis of patients with structural or shunt anomalies, especially in areas of the country where echocardiographic expertise is very much lacking.
Long-distance imaging - Videoconference - Contrast echocardiography - Diagnosis - Structural or shunt anomaly
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1. Warnes CA, Liberthson R, Danielson GK, Dore A, Harris L, Hoffman JI, Somerville J, Williams RG, Webb GD. Task force 1: the changing profile of congenital heart disease in adult life. J Am Coll Cardiol 2001;37:1170–1175. PubMed CrossRef
2. Baumgartner H, Bonhoeffer P, De Groot NMS, de Haan F, Deanfield JE, Galie N, Gatzoulis MA, Gohlke-Baerwolf C, Kaemmerer H, Kilner P, Meijboom F, Mulder BJM, Oechslin E, Oliver JM, Serraf A, Szatmari A, Thaulow E, Vouhe PR, and Walma E. ESC Guidelines for the management of grownup congenital heart disease (new version 2010). European Heart Journal 2010;31:2915–2957. PubMed CrossRef
4. Calleja HB, Bellosillo AB, Santos RJ et al. for the Philippine Heart Association, Council on Echocardiography, Philippine Society of Echocardiography. Guidelines for echocardiography: summary of penultimate statement. Phil J Cardiol 2004;32(4):157–162.
5. Quinones MA, Douglas PS, Foster E, Gorcsan J, Lewis JF, Pearlman AS, Rychik J, Salcedo EE, Seward JB, Stevenson JG, Thys DM, Weitz HH and Zogbhi WA. ACC/AHA clinical competence statement on echocardiography: a report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on Clinical Competence. J Am Coll Cardiol 2003;41(4):687–708. PubMed CrossRef
6. Randolph GR, Hagler DJ, Khandheria BK, Lunn ER, Cook WJ, Seward JB, and O’Leary PW. Remote telemedical interpretation of neonatal echocardiograms: impact on clinical management in a primary care setting. J Am Coll Cardiol 1999;34:241–245. PubMed CrossRef
7. Soliman OI, Geleijnse ML, Meijboom FJ, Nemes A, Kamp O, Nihoyannopoulos P, Masani N, Feinstein SB and Ten Cate FJ. The use of contrast echocardiography for the detection of cardiac shunts. Eur J Echocardiography 2007;8:S2–S12. CrossRef
8. Altman DG (1991) Practical statistics for medical research. London: Chapman and Hall.
10. Low D, York B, and Eisses MJ. A novel use for the Apple (4th generation) iPod Touch in the operating room. Surgical Innovation 2007;14:52–61. CrossRef
11. Armstrong DG, Giovinco N, Mills JL, and Rogers LC. FaceTime for physicians: using real time mobile phone-based videoconferencing to augment diagnosis and care in telemedicine. Open Access Journal of Plastic Surgery 2007;11: 212–217.
12. Eaton SE. How to Use Skype in the ESL/EFL Classroom. The Internet TESL Journal [Internet]. 2010 November [cited 2012]; 16(11). Available from: http://iteslj.org/Techniques/Eaton-UsingSkype.html .
13. ealth insurance portability and accountability act of 1996. Public Law 104-191—August 21, 1996.
14. Lavey-Heaton M. FaceTime calls are encrypted, HIPAA-compliant. [Internet]. [Place unknown]: [publisher unknown]; 2011 [cited 2012]. Available from: http://www.tuaw.com/2011/09/21/facetime-calls-are-encrypted-hipaa-compliant.
15. Beaver K and Davis PT. Understanding WEP Weaknesses. [Internet]. [Place unknown]: Wiley Publishing; Retrieved 2010-01–10.
16. Sable C, Roca T, Gold J, Gutierrez A, Gulotta E, Culpepper W. Live transmission of neonatal echocardiograms from underserved areas: accuracy, patient care, and cost. Telemed J 1999;5(4):339–47. PubMed CrossRef
18. Sharma S, Parness IA, Kamenir SA, Ko H, Haddow S, Steinberg LG, Lai WW. Screening fetal echocardiography by telemedicine: efficacy and community acceptance. J Am Soc Echocardiogr 2003;16(3):202–8. PubMed CrossRef
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