Realtime fetal ultrasound by telemedicine in Queensland. A successful venture?

Identifying enablers and barriers to teleultrasound use for remote settings: A scoping review

Introduction/Purpose

Teleultrasound connects expert point-of-care ultrasound (POCUS) users with remote community and rural sites. Evolving technologies including handheld devices, upgraded image quality, and the ability to transmit over low bandwidth connections increase POCUS education, accessibility, and clinical integration. Potential teleultrasound venues include low-resource settings, prehospital care, and austere environments (high altitudes, microgravity, conflict zones, etc.). This scoping review assesses current teleultrasound uses and identifies implementation enablers and barriers.

Methods

Using the PRISMA-ScR checklist, PubMed, Embase, and Cochrane were searched on 16 August 2024 for teleultrasound studies. Two reviewers independently screened results and abstracted data using a data collection table. 165 articles met the following inclusion criteria: research studies describing teleultrasound, involving humans, including healthcare workers, with remote point-of-care or medical ultrasound use, in any setting, and in English.

Results

Teleultrasound studies were reported in most specialties and across all continents. Most were prospective (100 studies), review articles (27), or case studies (14). Study quality was variable, with 28 high quality, 77 moderate, 54 low, and 6 very low (GRADE assessment tool). Common themes that emerged include (1) type of image transmission method utilised, (2) remote provider training and curriculum development, (3) feedback methods between expert and novice users, (4) technologies and devices used, and (5) enablers and barriers to guide future teleultrasound implementation and training strategies.

Conclusion

Overall, the teleultrasound literature is heterogeneous in setting, design, and quality outcomes. As teleultrasound technology evolves and the use expands, future studies should standardise protocols and ensure image quality fidelity to optimise remote patient care.

Fetal Tele-Echocardiography-An Approach to Improving Diagnosis and Management

Introduction: Antenatal diagnosis of cardiac abnormalities and counselling parents about postnatal care require a multidisciplinary team, which includes a paediatric cardiologist, a neonatologist, and a fetal medicine physician. Some of these kinds of expertise are not available in all centres with fetal medicine expertise. However, with modern technology, this could be provided remotely. Our objective was to assess the feasibility and outcomes of prenatal multidisciplinary tele-echocardiography diagnostic and counselling services. Materials and Methods: Two centres based in separate countries provided a joint diagnostic and counselling service over a period of 14 months. The primary centre performed the fetal echocardiography with a Voluson E10 machine, and images were transmitted live using Zoom OPS system with video-consultation and counselling. The fetal echo was performed using the ISUOG Guidelines check list. Results: There was an initial feasibility period of 2 months during which 10 women whose fetuses had normal hearts were scanned to test the workability of the system. Over a period of 12 months, 513 high-risk fetuses were then scanned, and out of these, 27 had congenital malformations. The most common were hypoplastic left heart syndrome (HHLS) and atrio-ventricular septal defect. Tele-echocardiography and counselling were successful in all the cases. Satisfaction with the service was 3.8/4, with the main limitation being the need for further referral to a tertiary centre for delivery. Conclusions: Tele-echocardiography is reliable, and when combined with live counselling and support from a paediatric cardiologist, it is an option acceptable to patients. The greatest benefit was from being counselled by a team of experts at a single consultation rather than having to travel to another centre for consultation. With rapidly evolving technology, making video transmission easier and less expensive, we feel that consideration should be given not only to the development of tele-echocardiography but also to extending it to other aspects of fetal medicine.

The Potential of Tele-Ultrasound, Handheld and Self-Operated Ultrasound in Pregnancy Care: A Systematic Review

OBJECTIVE

To explore the use of tele-ultrasound and handheld or self-operated ultrasound in pregnancy.

METHODS

A systematic search provided 31 studies. The risk of bias for each study was assessed. Results were analyzed and presented in a narrative overview in four domains: tele-ultrasound, patient-operated ultrasound, handheld devices and low- and middle-income countries (LMIC).

RESULTS

The quality of studies was generally low or fair based on the NIH Quality Assessment Tools. Fetal tele-ultrasound services (11 studies) are feasible and especially helpful in rural areas or with increased centralization of specialist care. Three studies with patient-operated ultrasound concluded its feasibility with good-to-high experiences. The use of handheld devices in pregnancy (eight studies) showed similar ultrasound results when compared to standard devices. In LMICs, innovative use of ultrasound (nine studies) can facilitate access to obstetric care performed by trained as well as unskilled caregivers combined with remote evaluation by an expert.

CONCLUSIONS

Innovations in ultrasound in pregnancy care have shown promising results for application. Although most studies demonstrated benefits for pregnant women or care providers, high-level evidence is scarce. High-quality studies on innovations are needed to assess medical outcomes, patient and provider experiences and costs.

A cost minimization analysis comparing asynchronous tele-expertise with face-to-face consultation for prenatal diagnosis in France

Timely detection of congenital anomalies using ultrasound improves neonatal care. As specialist sonographers are often geographically dispersed, they are sometimes requested to provide a second opinion via tele-expertise. The present study aimed to evaluate the economic impact of asynchronous tele-expertise in obstetric ultrasound care in private medical practice through a comparison with face-to-face consultations. We conducted a cost minimization analysis using decision tree modeling in order to determine whether asynchronous tele-expertise or face-to-face consultation had the lowest cost, under the assumption of equivalent effectiveness in terms of prenatal diagnosis. Costs were measured from the societal perspective. The data for the base case of our modeling came from a retrospective analysis of the clinical practice of an expert who had been conducting asynchronous tele-expertise for 4 years in France. The study included 260 patients for whom 322 requests for expert opinions were made by physicians/midwives from January 2016 to January 2020. The expected average total cost for tele-expertise for a patient was €74.45 (95% CI: €66.36-€82.54) compared to €195.02 (95% CI: €183.90-€206.14) for the conventional face-to-face strategy. Accordingly, using tele-expertise led to a statistically significant reduction of €120.57 in the average total cost per patient. A sensitivity analysis confirmed the robustness of the model produced. The results of the present study underline the efficiency of tele-expertise and highlight related economic benefits. Accordingly, they could inform public health policy on the dissemination of tele-expertise in the field of obstetric ultrasound care.

Implementation and evaluation of a pilot antenatal ultrasound imaging programme using tele-ultrasound in Ethiopia

INTRODUCTION

Ultrasound imaging is an important aspect of antenatal care, though access to antenatal ultrasound imaging is limited in many developing countries. The objective of this study was to evaluate a pilot programme which aimed to improve access to antenatal ultrasound for rural Ethiopians through enhanced training of healthcare providers (including midwives, nurses and clinical officers) with support remotely provided by obstetricians using a tele-ultrasound platform.

METHODS

Thirteen healthcare providers in the North Shoa Zone in Ethiopia completed training to enable them to perform antenatal ultrasound with the remote supervision of an obstetrician via a tele-ultrasound platform. Pregnant women attending an antenatal appointment at two facilities were offered an antenatal ultrasound exam performed by one of the healthcare providers. Image interpretations between obstetricians and healthcare providers were compared. Participants and healthcare providers were invited to complete a questionnaire regarding their experience with tele-ultrasound, and participants, healthcare providers and obstetricians were interviewed regarding their experience with the tele-ultrasound pilot programme.

RESULTS

2795 pregnant women had an antenatal ultrasound exam. Of 100 exams randomly selected to assess concordance between healthcare providers' and obstetricians' image interpretations, concordance ranged from 79% to 100% for each parameter assessed. 99.4% of participants surveyed indicated that they would recommend antenatal ultrasound using tele-ultrasound to friends and family. Themes relating to participants' experiences of having a tele-ultrasound exam were reduced travel and cost, equivalence in quality of virtual care to in-person care and empowerment through diagnostic information.

CONCLUSION

Healthcare provider-performed antenatal ultrasound - supported by obstetricians via tele-ultrasound - showed high levels of concordance, was well-received by participants and provided rural Ethiopian women with enhanced access to antenatal imaging.

Asynchronous tele-expertise (ASTE) for prenatal diagnosis is feasible and cost saving: Results of a French case study

OBJECTIVE

The objective of this study was to assess the potential of the use of asynchronous tele-expertise (ASTE) to provide prenatal diagnosis from a medical and economic point of view.

POPULATION

Patients screened by a midwife at a primary center.

METHODS

A technical and clinical evaluation was conducted retrospectively, and a cost minimization study compared asynchronous tele-expertise to face-to-face consultations that would have been performed without ASTE.

MAIN OUTCOME MEASURES

In our study we assessed the feasibility of ASTE, what were the origins of the requests for expertise, whether patients need to be moved and the reasons for doing so, and the costs of tele-expertise and conventional consultation.

RESULTS

In this retrospective analysis 322 advices from 260 patients were interpreted remotely via a platform. The results revealed a 90.68% feasibility of transmitting in a satisfactory and interpretable way ultrasound images and videos via the tele-expertise platform (292/322 files). In our series, asynchronous analysis allowed the required physician to make an accurate diagnosis and identify 74 (28.5%, 95% CI [23% -33.9%]) pregnancies associated with malformations and rule out abnormalities in 186 (71.5%, 95% CI [66.1% -77%]) of the cases. The ASTE was not associated with face-to-face consultations for 72.7% (189/260) of the patients, who without moving, were able to have access to a precise diagnosis by ruling out the presence of anomalies in 163/189 of these patients and confirming them in 26/189 patients. The practice of ASTE would result from a societal point of view, an average saving of 61.8% (€ 120.57) per patient compared to a face-to-face consultation.

CONCLUSION

The use of asynchronous tele-expertise (ASTE) using fetal ultrasound, is feasible and may contribute to increased diagnostic accuracy while generating a significant reduction in costs for society.

Ultrasound in Telemedicine: A Brief Overview

The delivery of healthcare from a distance, also known as telemedicine, has evolved over the past 50 years, changing the way healthcare is delivered globally. Its integration into numerous domains has permitted high-quality care that transcends the obstacles of geographic distance, lack of access to health care providers, and cost. Ultrasound is an effective diagnostic tool and its application within telemedicine has advanced substantially in recent years, particularly in high-income settings and low-resource areas. The literature in Pubmed from 1960–2020 was assessed with the keywords “ultrasound”, “telemedicine”, “ultrasound remote”, and “tele-ultrasound” to conduct a SWOT analysis (strengths, weaknesses, opportunities, and threats). In addressing strengths and opportunities, we emphasized practical aspects, such as the usefulness of tele-ultrasound and the cost efficiency of it. Furthermore, aspects of medical education in tele-ultrasound were considered. When it came to weaknesses and threats, we focused on issues that may not be solved immediately, and that require careful consideration or further development, such as new software that is not yet available commercially.

[Asynchronous Tele-Expertise (ASTE) in obstetrical ultrasound: Is it equivalent to face-to-face consultation?]

INTRODUCTION

The demand for remote advice has expanded since the advent of information and communication technology. This study aims to evaluate the use of asynchronous tele-expertise (ASTE) in providing a quality expert opinion in the field of obstetric ultrasound.

MATERIALS AND METHODS

Requests for expert opinions on pregnant patients were considered retrospectively over a 24-month period (01/09/2018 to 01/21/2020). All patients were initially seen in consultation with a midwife sonographer, located in Hyères, 82km from the expert's centre. In the event of unusual images, including one or more malformations on ultrasound screening, a second opinion was necessary. Responses were characterized as follows : possible or impossible to analyse images; ASTE alone or combined with a face-to-face consultation; and absence or presence of unusual images. Unusual images were classified as normal variants or recognised malformations. We analysed the outcomes of these pregnancies and assessed concordance between prenatal advice and postnatal outcome.

RESULTS

During the study period, we identified 174 referrals from 141 patients. Requests for advice were made by 3/174 (1.7%), 69/174 (39.7%), and 102/174 (58.6%) in the first, second, and third trimester of pregnancy, respectively. Overall, 115/141 (81.6%), 21/141 (14.9%), 4/141 (2.8%), and 1/141 (0.7%) patients were provided with one, two, three, and five opinions, respectively. In total, 37/141 (26.2%) patients required a face-to-face consultation, resulting in 38/174 (21.8%) opinions (one patient was seen twice). At least one unusual image was found for 27/141 (19.2%) patients and no unusual images were reported for 114/141 (80.8%) patients. Analysis of the pregnancy outcomes revealed a perfect correlation between prenatal advice and postnatal data, both for cases with unusual images and those without.

CONCLUSION

The preliminary results of our study reveal that ASTE is safe in terms of enabling an expert to answer a precise question formulated by a screener when confronted with images deemed to be unusual. Using this mode of communication, a tailored healthcare pathway may be defined for the mother and her foetus. This new type of practice cannot exist without establishing a genuine relationship of trust between the person requesting the opinion and the person who is asked to provide the opinion.

Examining ultrasound diagnostic performance improvement with utilization of maternal-fetal medicine tele-interpretation

BACKGROUND

Telemedicine can extend essential health services to under-resourced settings and improve the quality of obstetrical care. Specifically, the evaluation and management of fetal anomalies require perinatal subspecialists, rendering prenatal diagnosis essential, and may benefit from telemedicine platforms to improve access to care.

OBJECTIVE

This study aimed to evaluate the impact of a maternal-fetal medicine telemedicine ultrasound program on the diagnostic accuracy of fetal anomalies when used within practices where ultrasounds are interpreted by general obstetricians or family medicine physicians.

STUDY DESIGN

This was a cross-sectional study of all patients receiving care at 11 private obstetrical practices and imaging centers who had obstetrical ultrasounds performed from January 1, 2020, to July 6, 2020. All ultrasounds were performed by sonographers remotely trained under a standardized protocol and interpreted by maternal-fetal medicine physicians via telemedicine. Ultrasound characteristics and interpretation were extracted from ultrasound reports. Before the introduction of maternal-fetal medicine telemedicine, all ultrasound interpretations were reviewed by general obstetricians and family medicine physicians with reliance predominantly on the sonographer's impression. The primary outcome was potential missed diagnosis of a fetal anomaly, defined as an ultrasound designated as normal by a sonographer but diagnosed with an anomaly by a maternal-fetal medicine physician via telemedicine. This outcome serves as a proxy measure for anomaly diagnoses that would likely be missed without the supervision of a maternal-fetal medicine physician. The characteristics of the potential missed diagnoses were compared by type of scan and fetal organ system in univariable analysis. Moreover, a survey was conducted for sonographers and obstetrical providers to assess their perceptions of ultrasound interpretation via telemedicine.

RESULTS

Overall, 6403 ultrasound examinations were evaluated, 310 of which had a diagnosis of fetal anomaly by a maternal-fetal medicine physician (4.8%). Of the fetal anomalies, 43 were diagnosed on an anatomic survey (13.9%), and 89 were diagnosed as cardiac anomalies (28.7%). The overall rate of the potential missed diagnoses was 34.5% and varied significantly by type of ultrasound (anatomy scans vs other first-, second-, and third-trimester ultrasounds) (P<.01). Moreover, there were significant differences in the rate of the potential missed diagnoses by organ system, with the highest rate for cardiac anomalies (P<.01).

CONCLUSION

Expertise in maternal-fetal medicine telemedicine improves the diagnostic performance of antenatal ultrasound throughout pregnancy. However, there are implications for improving the quality of antenatal care, such as ensuring appropriate referrals and site of delivery, particularly for cardiac anomalies.

Telemedicine in Obstetrics

Telemedicine is an important modality of care delivery in the twenty-first century and has many applications for the obstetric population. Existing research has shown the clinical efficacy and improved patient satisfaction of many telemedicine platforms in obstetrics. Telemedicine has the potential to reduce racial and geographic disparities in pregnancy care, but more research is necessary to inform best practices. Developing cost-effective telemedicine programs and establishing health care policy that standardizes insurance reimbursement are some of the most important steps toward scaling up telemedicine offerings for obstetric patients in the United States.

Service user and staff acceptance of fetal ultrasound telemedicine

Objective

We present qualitative findings from interviews with frontline clinicians and service users of a fetal telemedicine service.

Methods

Semi-structured interviews with clinical stakeholders and service users were conducted, undertaken as part of a service evaluation. Data collection was undertaken by different teams, using interview schedules aligned to independent evaluation aims. Data were subjected to thematic analysis.

Results

Sonographers reported four main challenges: delivering a shared consultation; the requirement to resist scanning intuitively; communications during the scan; and restricted room space. Notwithstanding, all clinicians reported that participating women were accepting of the technology. Service users reported few concerns. The main benefits of fetal telemedicine were identified as upskilled staff, increased access to specialist support and improved management of complex pregnancies. Convenience was identified as the main benefit by service users, including savings in time and money from not having to travel, take time off work, and arrange childcare.

Conclusions

Service users and clinical stakeholders were accepting of the service. Service users reported satisfaction with communications during the consultation and awareness that telemedicine had facilitated local access to clinical expertise. Whilst clinical stakeholders reported challenges, the iterative nature of the evaluation meant that concerns were discussed, responded to, and overcome as the pilot developed. Clinical stakeholders’ perception of benefits for service users encouraged their acceptance. Moreover, the evaluation established that fetal ultrasound telemedicine is a viable method to access expertise safely and remotely. It provided demonstrable evidence of a potential solution to some of the healthcare challenges facing rural hospitals.

Review of Health Economics of Point-of-Care Testing Worldwide and Its Efficacy of Implementation in the Primary Health Care Setting in Remote Australia

There are important differences concerning health outcomes between the Australian population living in rural/remote regions and the urban population. Health care provision in remote areas, particularly in regions with a low number of inhabitants, is not without challenges. Aboriginal, rural and remote communities are therefore affected, as they face various obstacles in accessing health services, owing to geographical settings, difficulties in transportation to nearby hospitals, limited or inexistent local qualified personnel. The implementation of point-of-care testing could be a plausible solution to these challenges, as various point-of-care services that have been successfully put into action worldwide indicate towards positive clinical outcomes. Point-of-care units have a real potential in reducing morbidity and mortality in all population groups. This article aims to review the published literature on point-of-care testing around the world, with a focus on health economics and the feasibility of its implementation in Australian rural and remote regions.

Mobile Health Applications for Prenatal Assessment and Monitoring

BACKGROUND

A mobile health application is an exciting, fast-paced domain that is likely to improve prenatal care.

METHODS

In this narrative review, we summarise the use of mobile health applications in this setting with a special emphasis on both the benefits of remote monitoring devices and the potential pitfalls of their use, highlighting the need for robust regulations and guidelines before their widespread introduction into prenatal care.

RESULTS

Remote monitoring devices for four areas of prenatal care are reported: (1) cardio-tocography; (2) blood glucose levels; (3) blood pressure; and (4) prenatal ultrasound. The majority of publications are pilot projects on remote consultation, education, coaching, screening, monitoring and selective booking, mostly reporting potential medical and/or economic benefits by mobile health applications over conventional care for very specific situations, indications and locations, but not always generalizable.

CONCLUSIONS

Despite the potential advantages of these devices, some caution must be taken when implementing this technology into routine daily practice. To date, the majority of published research on mobile health in the prenatal setting consists of observational studies and there is a need for high-quality randomized controlled trials to confirm the reported clinical and economic benefits as well as the safety of this technology. There is also a need for guidance and governance on the development and validation of new apps and devices and for the implementation of mobile health technology into healthcare systems in both high and low-income settings. Finally, digital communication technologies offer perspectives towards exploration and development of the very new domain of tele-pharmacology.

Teleultrasound for pre-natal diagnosis: A validation study

Introduction/Purpose

There are no large validation trials comparing teleultrasound to on-site ultrasound. We aim to compare the sensitivity and accuracy of teleultrasound and demonstrate that teleultrasound is not inferior to on-site ultrasound in the pre-natal diagnosis of fetal anomalies.

Methods

All targeted ultrasounds performed between November 2010 and December 2012 were considered. We excluded studies performed at less than 17 weeks' gestation, on multiple gestations and for reasons other than an anatomical survey. Post-natal diagnoses were obtained from a state level mandatory birth defects surveillance programme. Descriptive statistics (sensitivity, specificity, positive and negative predictive values and accuracy) were calculated for both groups. A test of non-inferiority was performed, with the non-inferiority difference set at 0.15.

Results

The teleultrasound and on-site ultrasound groups consisted of 2368 and 3145 studies, respectively. The sensitivity of teleultrasound and on-site ultrasound was 57.46% and 76.57%, and the accuracy was 95.9% and 90.97%, respectively. The observed sensitivity difference was -0.1911. The accuracy, specificity, positive and negative predictive values of teleultrasound are similar to on-site ultrasound.

Discussion

Teleultrasound is inferior to on-site ultrasound in the detection of fetal anomalies; however, it has improved accuracy, as well as higher negative and positive predictive values. A negative teleultrasound is more likely to identify a non-anomalous fetus, and a positive teleultrasound is more likely to correctly identify an anomalous fetus.

Conclusion

Teleultrasound has an important role in pre-natal diagnosis for those patients unable or unwilling to travel for an on-site ultrasound.

EDUCATIONAL SERIES IN CONGENITAL HEART DISEASE: Prenatal diagnosis of congenital heart disease

This review article will guide the reader through the background of prenatal screening for congenital heart disease. The reader will be given insight into the normal screening views, common abnormalities, risk stratification of lesions and also recent advances in prenatal cardiology.

Factors Determining the Success and Failure of eHealth Interventions: Systematic Review of the Literature

Background

eHealth has an enormous potential to improve healthcare cost, effectiveness, and quality of care. However, there seems to be a gap between the foreseen benefits of research and clinical reality.

Objective

Our objective was to systematically review the factors influencing the outcome of eHealth interventions in terms of success and failure.

Methods

We searched the PubMed database for original peer-reviewed studies on implemented eHealth tools that reported on the factors for the success or failure, or both, of the intervention. We conducted the systematic review by following the patient, intervention, comparison, and outcome framework, with 2 of the authors independently reviewing the abstract and full text of the articles. We collected data using standardized forms that reflected the categorization model used in the qualitative analysis of the outcomes reported in the included articles.

Results

Among the 903 identified articles, a total of 221 studies complied with the inclusion criteria. The studies were heterogeneous by country, type of eHealth intervention, method of implementation, and reporting perspectives. The article frequency analysis did not show a significant discrepancy between the number of reports on failure (392/844, 46.5%) and on success (452/844, 53.6%). The qualitative analysis identified 27 categories that represented the factors for success or failure of eHealth interventions. A quantitative analysis of the results revealed the category quality of healthcare (n=55) as the most mentioned as contributing to the success of eHealth interventions, and the category costs (n=42) as the most mentioned as contributing to failure. For the category with the highest unique article frequency, workflow (n=51), we conducted a full-text review. The analysis of the 23 articles that met the inclusion criteria identified 6 barriers related to workflow: workload (n=12), role definition (n=7), undermining of face-to-face communication (n=6), workflow disruption (n=6), alignment with clinical processes (n=2), and staff turnover (n=1).

Conclusions

The reviewed literature suggested that, to increase the likelihood of success of eHealth interventions, future research must ensure a positive impact in the quality of care, with particular attention given to improved diagnosis, clinical management, and patient-centered care. There is a critical need to perform in-depth studies of the workflow(s) that the intervention will support and to perceive the clinical processes involved.

Teleultrasound: How Accurate Are We?

OBJECTIVES

Ultrasound serves an important role in the prenatal diagnosis of fetal structural anomalies. Recently, there has been increased use of teleultrasound protocols. We aimed to evaluate the sensitivity and accuracy of teleultrasound.

METHODS

We conducted an Institutional Review Board-approved retrospective cohort study determining the sensitivity and accuracy of teleultrasound. In addition, we evaluated the number of ultrasound examinations required to complete an anatomic survey. Only ultrasound examinations performed for anatomic surveys were included. Studies were excluded if performed before 16 completed weeks' gestation, if they had multiple gestations, or for reasons other than anatomy (eg, Doppler studies and fluid assessment). Prenatal diagnoses were compared with postnatal diagnoses obtained from a robust mandatory birth defects surveillance program that records all birth defects in the entire state, from deliveries before 20 weeks' gestation through infants up to 2 years of age.

RESULTS

A total of 2499 studies were evaluated; 2368 were included. The teleultrasound cohort had a congenital anomaly prevalence of 5.66%. The sensitivity of teleultrasound was 57.46%; the specificity was 98.21%; and the accuracy was 95.9%. Anatomic surveys were completed after 1 visit in 82% of patients, whereas 63% and 61% of the remaining patients required 2 and 3 visits, respectively.

CONCLUSIONS

Teleultrasound for prenatal diagnosis has similar sensitivity and accuracy as the published literature for on-site ultrasound. Further studies are needed to compare the sensitivity and accuracy within the same population and further validate this potentially cost-saving modality.

Fetal endoscopic telesurgery using an Internet Protocol connection: Clinical and technical challenges

Until recently, fetoscopic laser surgery to seal the placental anastomoses that cause severe twin-to-twin transfusion syndrome has been available in only a few centres worldwide. The technique typically takes a long time to learn. We have used a dedicated Internet Protocol (IP) connection for tele-education to assist the introduction of fetoscopic laser surgery to Australia. During the implementation of the international telemedicine link, there were multiple clinical and technical problems, which were eventually overcome. The quality of images and of video-sequences was comparable to that supported by an ISDN connection. Pictures of live surgery performed by an expert in Florida, USA, were transmitted and viewed by a novice team in Brisbane, Australia. The Australian team has performed 19 fetoscopic laser operations to date. Preliminary results are comparable to those from centres that have performed over 100 procedures.

Development of a combined telemedicine and Picture Archiving and Communications System for a tertiary hospital group

The new Mater Mother's Hospital in Brisbane, due to open in March 2008, will cater for the growing demand on maternity services in Queensland. The plan is to provide a comprehensive teleconsultation service to the whole of Queensland and to northern New South Wales for both teleradiology and telecardiology. The key to the Mater's plans for electronic health records will be the coming together of a Picture Archiving and Communications System (PACS), various clinical information systems, a new Patient Administration System (PAS) and the clinical portal system called Verdi. Clinicians will have online access to patient demographics from the PAS and to patients’ previous imaging studies from the PACS, prior to the real-time teleconsultation, so as to enhance the clinical value of the consultation. Developments in the areas of telemedicine and PACS appear capable of supporting each other to ensure that real-time teleconsultations by paediatric specialists can be provided to patients in remote areas, and at the same time the consultants can have access to a patient's images and medical records so as to provide a high standard of care.

Teleultrasound: historical perspective and clinical application

The health care of patients in rural or isolated areas is challenged by the scarcity of local resources, limited patient access to doctors and hospitals, and the lack of specialized professionals. This has led to a new concept in telemedicine: teleultrasonography (or teleultrasound), which permits ultrasonographic diagnoses to be performed remotely. Telemedicine and teleultrasonography are effective in providing diagnostic imaging services to these populations and reduce health care costs by decreasing the number and duration of hospitalizations and reducing unnecessary surgical procedures. This is a narrative review to present the potential clinical applications of teleultrasonography in clinical practice. The results indicate that although barriers persist for implementing teleultrasonography in a more universal and routine way, advances in telecommunications, Internet bandwidth, and the high resolution currently available for portable ultrasonography suggest teleultrasonography applications will continue to expand. Teleultrasound appears to be a valuable addition to remote medical care for isolated populations with limited access to tertiary healthcare facilities and also a useful tool for education and training.

Help is in your pocket: the potential accuracy of smartphone- and laptop-based remotely guided resuscitative telesonography

BACKGROUND

Ultrasound (US) examination has many uses in resuscitation, but to use it to its full effectiveness typically requires a trained and proficient user. We sought to use information technology advances to remotely guide US-naive examiners (UNEs) using a portable battery-powered tele-US system mentored using either a smartphone or laptop computer.

MATERIALS AND METHODS

A cohort of UNEs (5 tactical emergency medicine technicians, 10 ski-patrollers, and 4 nurses) was guided to perform partial or complete Extended Focused Assessment with Sonography of Trauma (EFAST) examinations on both a healthy volunteer and on a US phantom, while being mentored by a remote examiner who viewed the US images over either an iPhone(®) (Apple, Cupertino, CA) or a laptop computer with an inlaid depiction of the US probe and the "patient," derived from a videocamera mounted on the UNE's head. Examinations were recorded as still images and over-read from a Web site by seven expert reviewers (ERs) (three surgeons, two emergentologists, and two radiologists). Examination goals were to identify lung sliding (LS) documented by color power Doppler (CPD) in the human and to identify intraperitoneal (IP) fluid in the phantom.

RESULTS

All UNEs were successfully mentored to easily and clearly identify both LS (19 determinations) and IP fluid (14 determinations), as assessed in real time by the remote mentor. ERs confirmed IP fluid in 95 of 98 determinations (97%), with 100% of ERs perceiving clinical utility for the abdominal Focused Assessment with Sonography of Trauma. Based on single still CPD images, 70% of ERs agreed on the presence or absence of LS. In 16 out of 19 cases, over 70% of the ERs felt the EFAST exam was clinically useful.

CONCLUSIONS

UNEs can confidently be guided to obtain critical findings using simple information technology resources, based on the receiving/transmitting device found in most trauma surgeons' pocket or briefcase. Global US mentoring requires only Internet connectivity and initiative.

The Cost-Effectiveness of Prenatal Detection for Congenital Heart Disease Using Telemedicine Screening

We estimated the longer-term cost-effectiveness of using telemedicine screening for prenatal detection of congenital heart disease (CHD). One hospital in south-east England with a telemedicine service was connected to a fetal cardiology unit in London. A UK health service perspective was adopted. Evidence on costs and outcomes for standard-risk pregnant women during the antenatal period was based on patient-level data. Extrapolation beyond the end of the study (just after delivery) was carried out for the lifetime of children born with and without CHD. Expert opinion and data from published sources was used to populate a decision model. Future costs and benefits were discounted. The main outcome was quality-adjusted life years (QALYs) and results were expressed as cost per QALY gained. Various one-way sensitivity analyses were conducted. The model showed that offering telemedicine screening by specialists to all standard-risk pregnant women was the dominant strategy (i.e. cheaper and more effective). The sensitivity analyses found that the model was robust, and that telemedicine remained the most cost-effective strategy. The study showed that it would be cost-effective to provide telemedicine examinations as part of an antenatal screening programme for all standard-risk women.

Potential Use of Remote Telesonography as a Transformational Technology in Underresourced and/or Remote Settings

Mortality and morbidity from traumatic injury are twofold higher in rural compared to urban areas. Furthermore, the greater the distance a patient resides from an organized trauma system, the greater the likelihood of an adverse outcome. Delay in timely diagnosis and treatment contributes to this penalty, regardless of whether the inherent barriers are geographic, cultural, or socioeconomic. Since ultrasound is noninvasive, cost-effective, and portable, it is becoming increasingly useful for remote/underresourced (R/UR) settings to avoid lengthy patient travel to relatively inaccessible medical centers. Ultrasonography is a user-dependent, technical skill, and many, if not most, front-line care providers will not have this advanced training. This is particularly true if care is being provided by out-of-hospital, “nontraditional” providers. The human exploration of space has forced the utilization of information technology (IT) to allow remote experts to guide distant untrained care providers in point-of-care ultrasound to diagnose and manage both acute and chronic illness or injuries. This paradigm potentially brings advanced diagnostic imaging to any medical interaction in a setting with internet connectivity. This paper summarizes the current literature surrounding the development of teleultrasound as a transformational technology and its application to underresourced settings.

User's perceptions of remote trauma telesonography

We established a pilot tele-ultrasound system between a rural referring hospital and a tertiary care trauma centre to facilitate telementoring during acute trauma resuscitations. Over a 12-month period, 23 tele-ultrasound examinations were completed. The clinical protocol examined both the Focused Assessment with Sonography for Trauma (FAST) and the Extended FAST (EFAST) for pneumothoraxes. Twenty of the examinations were conducted during acute trauma resuscitations and three during live patient simulations. FAST examinations were completed in all 23 cases and EFAST examinations in 17 cases. There were 18 clinical users, of whom 14 completed a survey (76% response rate). Overall, 93% of respondents were either satisfied or very satisfied with the telemedicine interaction and agreed or strongly agreed that the technology could potentially benefit injured patients in the far north of Canada. In addition, 93% of the respondents felt that the project had improved collegiality between the two institutions involved. The majority of respondents (71%) agreed or strongly agreed that the project had improved their ultrasound skills. We believe that as further experience is obtained, tele-ultrasound will prove to be an important aid to the care of remotely injured and ill patients.

Evaluation of satisfaction of parents with the use of videoconferencing for a pediatric genetic consultation

Telegenetics is a new development in the service delivery of Genetic Services in Australia. This project was designed to establish if it was an acceptable alternative to a face-to-face consultation in the genetic assessment of intellectual disability, including morphological assessment, of the patient. Ten children from two outreach clinics in rural NSW who were referred by their pediatrician were assessed by a single geneticist via telehealth and then seen again face-to-face as a 'gold standard'. Satisfaction surveys were then sent to both the parents and the referring pediatricians. After the face-to-face appointment, the clinical geneticist reviewed the recordings of both the transmitted footage and the high definition footage that was sent separately. There were very few morphological findings missed by the telegenetic assessments. The discrepancies that were noted could decrease in frequency as staff become more familiar with the methods. The parents of the patients reported no problem with the cameras and telehealth. They would have preferred face-to-face appointment but would be happy to have the telehealth appointment if it meant being seen earlier. This pilot study suggests that clinical genetic diagnostic assessment could be performed by telemedicine.

Telesonography: foundations and future directions

The practice of telesonography has yielded promising results in several domestic and international projects aimed at providing basic sonography services. Common themes that recur within telesonography-based research include the quality of transmitted images, clinical applications, and technical and nontechnical barriers to implementation. The research base continues to grow in concert with expanding telecommunications capabilities and refinement of small portable sonographic devices. Persistent barriers to the deployment of telesonography systems include a lack of telecommunications access, a lack of standard training and operational protocols, and a paucity of research regarding the long-term health impact of telesonography within target communities. Telesonography may be used directly to improve the standard of care within a given community; however, limited resources and interest may prevent sustained operations. Future projects may use telesonography to supplement the training of health care providers in remote locations in an effort to establish permanent sonography services for their respective communities.

The clinical and technical evaluation of a remote telementored telesonography system during the acute resuscitation and transfer of the injured patient

BACKGROUND

Ultrasound (US) has an ever increasing scope in the evaluation of trauma, but relies greatly on operator experience. NASA has refined telesongraphy (TS) protocols for traumatic injury, especially in reference to mentoring inexperienced users. We hypothesized that such TS might benefit remote terrestrial caregivers. We thus explored using real-time US and video communication between a remote (Banff) and central (Calgary) site during acute trauma resuscitations.

METHODS

A existing internet link, allowing bidirectional videoconferencing and unidirectional US transmission was used between the Banff and Calgary ERs. Protocols to direct or observe an extended focused assessment with sonography for trauma (EFAST) were adapted from NASA algorithms. A call rota was established. Technical feasibility was ascertained through review of completed checklists. Involved personnel were interviewed with a semistructured interview.

RESULTS

In addition to three normal volunteers, 20 acute clinical examinations were completed. Technical challenges requiring solution included initiating US; audio and video communications; image freezing; and US transmission delays. FAST exams were completed in all cases and EFASTs in 14. The critical anatomic features of a diagnostic examination were identified in 98% of all FAST exams and a 100% of all EFASTs that were attempted. Enhancement of clinical care included confirmation of five cases of hemoperitoneum and two pneumothoraces (PTXs), as well as educational benefits. Remote personnel were appreciative of the remote direction particularly when instructions were given sequentially in simple, nontechnical language.

CONCLUSIONS

The remote real-time guidance or observation of an EFAST using TS appears feasible. Most technical problems were quickly overcome. Further evaluation of this approach and technology is warranted in more remote settings with less experienced personnel.

Cost implications of introducing a telecardiology service to support fetal ultrasound screening

A district hospital in south-east England used a telecardiology service for fetal cardiac diagnosis alongside an existing arrangement for referring pregnant women directly to perinatal cardiologists in London for detailed fetal echocardiography. Women were identified for referral according to local protocols when having a second trimester anomaly scan. For the telemedicine referrals, the sonographers video-recorded images from the anomaly scans for transmission during monthly videoconferences. The cost of the women's antenatal care was calculated from the specialist assessment until delivery, while family costs were collected in a postal survey. Over 15 months, telemedicine was used in 52 cases, while 24 women were seen in London. The London women were more likely to have had an ultrasound abnormality (29% v 10%, P = 0.047). A telemedicine assessment of 5 min duration was more costly than an examination in London (mean cost per referral of £206 v £74, P < 0.001). However, the telecardiology service was cost neutral after 14 days and for the extended period until delivery. Travel costs for London women averaged £37 compared with £5.50 for the telemedicine referrals. Telemedicine may be useful to support perinatal cardiologists in the UK whose workloads are expanding in response to improved standards in antenatal ultrasound screening.

Characteristics of successfully implemented telemedical applications

Background

There has been an increased interest in the use of telemedical applications in clinical practice in recent years. Considerable effort has been invested in trials and experimental services. Yet, surprisingly few applications have continued beyond the research and development phase. The aim of this study is to explore characteristics of successfully implemented telemedical applications.

Methods

An extensive search of telemedicine literature was conducted in order to identify relevant articles. Following a defined selection process, a small number of articles were identified that described characteristics of successfully implemented telemedical applications. These articles were analysed qualitatively, drawing on central procedures from Grounded Theory (GT), including condensation and categorisation. The analysis resulted in a description of features found to be of importance for a successful implementation of telemedicine. Subsequently, these features were discussed in light of Science and Technology studies (STS) and the concept of 'social negotiation'.

Results

Telemedical applications introduced into routine practice are typically characterised by the following six features: 1) local service delivery problems have been clearly stated, 2) telemedicine has been seen as a benefit, 3) telemedicine has been seen as a solution to political and medical issues, 4) there was collaboration between promoters and users, 5) issues regarding organizational and technological arrangements have been addressed, and 6) the future operation of the service has been considered.

Conclusion

Our findings support research arguing that technologies are not fixed entities moving from invention through diffusion and into routine use. Rather, it is the interplay between technical and social factors that produces a particular outcome. The success of a technology depends on how this interplay is managed during the process of implementation.

The TERESA project: from space research to ground tele-echography

Ultrasound examinations represent one of the major diagnostic modalities of future healthcare. They are currently used to support medical space research but require a high skilled operator for both probe positioning on the patient's skin and image interpretation. TERESA is a tele-echography project that proposes a solution to bring astronauts and remotely located patients on ground quality ultrasound examinations despite the lack of a specialist at the location of the wanted medical act.