Telemedicine is a young science that integrates innovations of information-technology and telecommunications into medical science. Telecardiology, a branch of telemedicine, deals with monitoring as well as diagnosing of cardiac patients at a distance using telecommunication technology. Despite extraordinary advancements in the field of Telecardiology, death rate due to cardiac diseases is very high. Telecardiology is a proven tool to predict cardiac disturbances and improve this ratio, yet over the years it faces several challenges preventing its implementation to the fullest. This paper discusses various aspects of Telecardiology in brief and focuses on challenges faced towards its implementation.
According to ‘Heart disease facts’ published by Center of Disease control and Prevention, 1 in every 4 deaths is due to heart disease. About 47% of cardiac deaths occur outside a hospital, suggesting failure of laymen to act on early warning signs and also undue prolonged door-to-balloon time. This all can be reduced with the help of telemedicine.
According to WHO, Telemedicine can be defined as “The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities” Telecardiology is a branch of telemedicine with a vast range of applications ranging from real-time video consultation to store and forward EKGs as well as home-health monitoring.
Various tools and technologies as discussed below have been used to help prevent as well as treat heart diseases without physical presence of physicians.
Tools of Telecardiology
The electrocardiogram (EKG or ECG) is a machine that records the electrical signals of the heart either digitally or on paper. The EKG is used to identify the heart rate, heart rhythm and diagnose heart arrhythmia, heart attacks, pacemaker function and heart failure. This is the first test done it identify any heart related ailments.
Echocardiogram is also known as echo, echocardiography or diagnostic cardiac ultrasound. This test uses ultrasound technology-high frequency sound waves to create a picture of the heart’s shape. This is the second test the doctor orders if there is problem with the EKG. This test requires a specialized technician.
The third test is the Vascular Studies, which checks the blood flow in arteries and veins. The study uses high-frequency sound waves to measure the amount of blood flow in the veins and arteries. There are two types of vascular studies a doctor may recommend. The first one is Doppler ultrasound, which allows a physician to see blood flow through arteries and veins.
This is helpful in diagnosis because the amount of blood pumped with each heartbeat is a sign of how large a vessel’s opening is. This ultrasound can help find abnormal blood flow in a vessel or a blockage in a vessel. The second type of vascular study is the color Doppler, an advanced form of Doppler ultrasound, this ultrasound uses different colors to show the direction of blood flow in the arteries and veins.
The Stress Test also called an excursive test has to be done in facility with a specialized technician and doctor present. Patients walk on treadmill which will monitor heart rhythm, blood pressure and breathing. If stress test doesn’t pinpoint the cause, the nuclear stress test is administered. This nuclear stress test uses radioactive dye and an imaging machine to create pictures showing the blood flow to the heart and measures blood flow while patient is at rest and active. This test can only be run under the supervision of cardiologist and is typically found only at large hospitals.
A cardiologist may also order a Holter monitor, which is like a small portable EKG machine that records heart activity for 24-48 hours. They may also order a 30 Day Event monitoring which is the recording of EKG for 30 days for patients with fainting, dizziness, or arrhythmia. Additionally, the cardiologist may order blood work to test for Apolipoproteins, C-reactive protein (CRP) and Cardiac enzyme studies. This all can be conducted at local laboratories or at local health facility and reports sent to cardiologist/ specialist via internet. Various other tools are also being used and mentioned during the course of the paper.
Advantages of Telecardiology
Grasping the latest telemedicine exercises can empower preparing to achieve different favorable circumstances. We can cut down medical coverage costs, drive up preparing adequacy and pay, give our patients better access to healthcare organizations, and finally get progressively euphoric, increasingly valuable patients.
In 2002, an examination by Molinari et al. of 100 General Practitioners (GP) showed one hundred and thirty-four out of 456 patients giving cardiovascular sort indications and were suspected to have veritable coronary occasions. In any case, using a telecardiology service, it was unhesitatingly shown that 84 out of the 134 patients with suspected coronary occasions had no ECG variations from the norm at all. All things considered, superfluous hospitalization was maintained a strategic distance from.
Telecardiology gadgets are small, portable and more often moved effortlessly inside training or can even be taken out into the network. They can bolster the administration of those GPs accessible if the need arises and would demonstrate basic treatment to those rehearsing in remote territories. From a patient’s point of view, it is increasingly advantageous and agreeable to experience ECG testing in one’s very own home or neighborhood home-health center, instead of in a healing facility or ER. These gadgets take into account a progressively helpful utilize1.
More Convenient and Accessible Patient Care
As per an ongoing Cisco worldwide survey, 74% of patients incline toward simple access to medicinal services benefits over face to face connections with suppliers. In the present human services world, accommodation is the key. Patient who live in remote areas or are homebound or can’t take off time from work, can get access to instant care. Video conferencing, cell phone applications, and online administration frameworks associate more patients with suppliers than any other time in recent memory.
Healthcare Cost Savings
Remote examination, home-health centers and electronic information stockpiling essentially lessen medicinal services costs. It additionally lessens superfluous non-pressing Emergency room visit costs and saves with transportation costs for ordinary checkups. Past these general cost-funds, it can help support specialists’ income by transforming accessible hours into billable time, drawing in new patients and diminishing no-appears, and notwithstanding decreasing overhead for doctors who choose to change to an adaptable work-from-home model for part of the week.
Extended Specialist and Referring Physician Access
In the U.S., for each 100,000 country patients, there are just 43 authorities available5. These patients persevere through longer drives, waiting period and experience difficulty getting lifesaving treatment for explicit illnesses or unending consideration designs. Telecardiology can help refer the patients to the explicit doctors they require, instantly. Or on the other hand, if an expert hoping to grow tolerant populace, he/she can achieve a more extensive geographic area.
Increased Patient Engagement
Appointing the patients through Telecardiology services can enable them to keep up care schedules6. Virtual visits not just promise patients that their specialists are accessible and associated with their consideration but also it makes easier for them to connect with inquiries, report early cautioning signs, and make a subsequent arrangement to ensure they’re on track.
Better Patient Care Quality
Patients can address medicinal services issues rapidly using consultation applications and find out about treatment alternatives within minutes. Recently with the development of artificial intelligence, detection of abnormalities will be much faster- by sending details of abnormalities automatically to provider before even the patient recognizing it. This is still under research right now.
Challenges of Telecardiology
Even though telecardiology being the most successful branch it still has many challenges that needs to be fixed for better patient care. Fixing these short coming might take time but eventually it will be fruitful.
Cost Effective or Ineffective?
The cost of telecommunication system, particularly data management apparatus and training of medical professionals is quite high1. Many programs reported use of one-time funding and reimbursement challenges tends to hamper their efforts8.
The standardization of the components related to telecardiology is very important for ensuring successful and secured delivery of quality healthcare, which is lacking to a great extent. The infrastructure of some of the hospitals in rural area is restricted and not adequate to support the systems. Therefore, for the development of the services related to telecardiology a huge amount is needed to be invested and many of the hospitals as a result of inadequate amount of funding cannot deliver good quality of healthcare through telemedicine.
Quality of Care and Legalities
One of the major causes for its failure is lack or error while examination is done, as physical examination is limited, it may lead to failure of the whole treatment done. The readmission rates are also high with the telecardiology in rural area (though depends on number of factors) it’s higher than it is usually when the patient is admitted into the hospital. Establishing compatible infrastructure in doctors and clinical settings is difficult.
For example the general practitioners/ specialists are not trained enough for using the existing or updated technology, leading to increased chances of errors/and miscommunication. In Children’s Mercy hospital, Kansas had failed telemedicine because the infrastructure was not supportive enough for telemedicine11.
The next problem is doctors also have to comply with the legal issues. For example, a doctor is practicing in 10 different states for telemedicine/telecardiology, he/she has to get license for all those states and understand and comply with the laws for every state, which is altogether a lot time consuming and costs a lot of money27. The clinicians are not experienced enough, few times and therefore, they might not know the limitations of the associated systems and might miss a critical clinical finding all leading to failure of telecardiology.
There are sometimes cultural, social and language difference between the general practioners and specialist or specialist and patient, leading to communication gap 24/7 availability of consultants are required in emergency cases which is difficult and is not yet achieved. Also in such cases it will be complicated on whom to hold liable for a failed medical case or death in worst case- the physician for missed diagnosis or tele-provider for unclear video which led to misinterpretation or patient for not revealing all the signs and symptoms? Mobile telecardiology can be helpful in such cases to fill-up their availability on site33.
Patient Related Challenges
Sometimes, patients are not literate enough regarding the healthcare issues or the latest technology and so making them understand the things is sometimes difficult. The patients are not supportive sometimes for medication adherence and as they do not take medications as per indications, it results into failure of the whole treatment.
Convincing and implementing the integration of wearable sensors and biological monitors into patient’s daily living routine is occasionally difficult. The design of the telecardiology components is so complicated at times leading to making its use almost negligible especially in the case of emergency and for older people it is even more difficult. Even some of the survey conducted concluded that complicated operations act as a barrier for older people for adopting Telecardiology tools into their routine life5.
The time required per application is sometimes too much as the statistics show that for a single application it might take up to minutes long, though it depends on a number of factors and there are life death situations for many of the cardiac diseases patients, so it might cost someone his/her life if it would take this amount of time.
Patients must commit to taking the time to understand the technologies and the limitations associated with telemedicine. Patients not being committed leads to issues where scheduling a home-based consultation can potentially have technical issues such as browser or webcam incompatibility or patient not able to perform test as required or them missing video appointment as they are busy with household chores especially house-women. Patient compliance is a big question while using these hand-held devices which might lead to errors in diagnosis15.
The technology is advancing day by day and along with that the problems associated with its security and confidentiality has also increased. So, the protection of the data is a major issue nowadays and even statistics indicates that almost 3.5 million people’s data related to healthcare has been breached in 2018 in the United States21.
The whole basis of telemedicine lies on Networking. The administrative team sometimes lacks a unified vision leading to improper implementation and working of the whole thing. This might end up leading to technological and financial crisis. The bandwidth and connectivity available in some of the rural areas is a challenging task as telecardiology network is majorly dependent on the bandwidth and connectivity.
Minimum of 20 Mbps speed is needed for real-time consultation, but 40% of population residing in rural area does not have availability of this amount of speed of connectivity/ internet connectivity. Transmission in wireless channels gets more challenging as they need 3G wireless networks which are hard with low bandwidth in rural areas20.
Low quality of health informatics records like EKG or echocardiogram or clinical progress reports has a risk of misdiagnosis and treatment error1. Speaking of delayed patient care, due to the low bandwidth and inexperienced professional issues it takes a lot of time to register patient’s specifications. To add on to this the devices consume time to launch1. Well, often all believe that more is better but this is not the case with data.
The problem is ability of collecting the data is not matching with the ability to support, manage and filter the data. There is too much of data to be managed with not enough structure in place. With the advent of smart-watch technology capable of reporting heart rates fluctuations directly to the healthcare provider and millions of people using it, managing such a big data and scrutinizing those at high risk, eliminating false-positive alerts and reaching out to all those is quite challenging and bound to ignorance.
Issues regarding the choice of approach for a specific telemedicine program is also challenging. For example, interactive real-time telemedicine has greater overheads than “store-and-forward” approaches (e-mails, pre-recorded images/videos, etc.), but permits interaction and provides more immediate results. However, the store-and-forward approach may be fully sufficient for the purposes of telemonitoring of patients with implantable devices, where data collection has already been performed by the device itself3.
Some of the patients or doctors prefer in person consultation only, so making either of them understand the aspects and importance of telecardiology is difficult at times.
The barriers/challenges can be summarized as there is a further need for carrying out randomized controlled trials on a large, longitudinal scale and cost-efficacy data to evaluate these findings on a wider scale, as much resources or research is not available in order to successfully implement and make Telecardiology services work and gain its meaningful use.
Cardiac diseases are the largest contributors to death accounting to 43,772 deaths in Texas state alone according to 2016 CDC report. Over the years Telecardiology services have proved to provide adjunct to efforts for preventing deaths due to heart diseases and if services are adopted at high rates, results are bound to improve significantly.
Recently, based on HIMSS Analytics study report there is 3.5 % increase in telemedicine adoptions rate every year which is still 61.3% in 2016. Surprisingly, despite higher adoption rates, use of clinical grade patient monitoring is only 9.7% of different methods used to provide telemedicine services, which is very low. A Comprehensive implementation of Telecardiology services is not observed.
Cost; security; patient as well as healthcare worker experience; administrative as well as reimbursement procedures still poses as barrier to successful implementation of Telecardiology services. According to one report in 2017, 33 states of USA are graded into ‘F’ category for Medicaid provided Home health services which denotes the lack of basic infrastructure for the implementation of technology.
Telecardiology offers a great promise to prevent and reduce death due to heart diseases by early diagnosis, continuous monitoring and thus reducing door-to-balloon time. Major challenge in front of us today is commitment from patients and providers to learn the new technology and provide its meaningful use.
Instead of just reaching out these services to maximum people, comprehensive efforts should be made to achieve broader patient engagement, acquiring new patients by consumerism initiative, joining local organizations to form networks, increasing home-health center. Last but not the least, clear and detailed guidelines regarding federal rules and reimbursement policies should also be considered.