Use of Telemedicine Applications between Continents

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1 Use of Telemedicine Applications between Continents Ricardo Muñoz, MD, FAAP, FCCM, F.A.C.C. Chief, Cardiac Intensive Care Unit Medical Director, Global Business and Telemedicine Director, Cardiac Recovery Program Associate Professor Critical Care Medicine, Pediatrics and Surgery University of Pittsburgh Children s Hospital of Pittsburgh of UPMC

2 NO DISCLOSURE

4 Telemedicine in extreme situations

5 Problems in Specialized Health Care Around the World Insufficient specialized staff Difficult access to current technology Problems with diagnosis and resulting cost implication High morbidity and mortality

6 How can Telemedicine help to solve this problem? Accessibility to the opinions of highly qualified specialists in high-performance centers Sharing of information is key in order to improve the efficacy of any health system Education

7 How do we do it? Satellite Fiber optic Internet network

8 History of Telemedicine in Pediatric Cardiac Critical Care Children s Hospital of Pittsburgh of UPMC

9 PCCC Current Problem in the US Great deficit of cardiac intensivists 72 pediatricians ever certified in PCCC Among them 45 currently meeting MOC requirements in both CCM & Cardiology Only 32 meet MOC requirements in general pediatrics, critical care and cardiology

10 Recommendations from the Association for European Pediatric Cardiology for Training in Pediatric Cardiac Intensive Care Eduardo da Cruz Denver, USA Evelyn Lechner Linz, Austria Brigitte Stiller Freiburg, Germany Ricardo Munoz Pittsburgh, USA Maurice Beghetti Geneva, Switzerland Ulrich Fakler Munich, Germany Nikolaus Haas Bad Oeynhausen, Germany Cardiol Young Aug;21(4):480-4

11 What about the rest of the world?

12 Agreement with Fundacion Valle de Lili - Education and training - Medical advice Cali, Colombia Fundacion Valle de Lili

13 Telemedicine cart: H.3.23 Videoconferencing solution Videoconferencing unit LifeSize_ (Austin, TX) Polycom_ (Pleasanton, CA) HDX inch LCD screen Coder: Advanced Encryption Standard

14 Connectivity H.323 Video Bandwidth 520 Mbps Polycom (Pleasanton, CA) HDX7000: Children s Hospital of UPMC LifeSize_ (Austin, TX): Fundacion Valle de Lili

15 Ecmo Video

16 RACHS-1 Number of Procedures Pre-Telemedicine N procedures Category 1: 39 Category 2: 33 Category 3: 32 Category 4: 11 Category 5: 0 Category 6:

17 RACHS-1 Number of procedures Post-Telemedicine Category 1: 21 Category 2: 45 Category 3: 43 Category 4: 28 Category 5: 0 Category 6: 0 N procedures

18 %

19 TELEMEDICINE and e-health, VOL. 18 NO. 2 MARCH 2012

20 Results of survey Telemedicine in Pediatric Cardiac Critical Care 100% would recommend the telemedicine system 100% would use the telemedicine system in future TELEMEDICINE and e-health, VOL. 18 NO. 2 MARCH 2012

21 Results of survey Telemedicine in Pediatric Cardiac Critical Care TELEMEDICINE and e-health, VOL. 18 NO. 2 MARCH 2012

22 e-cicu - Clinical rounds Medellín Bucaramanga Cali

23 e-cicu activities TOTAL: 436 Starting from July 15th, Source: CHP ecicu Documentation database

24 e-cicu activities July 2011 April 2012 Activity Number (%) ecicu Center 3 (Colombia) Total consults 436 Monthly mean 44 Preop/medical 173 (40) Postop 263 (60) Echo directions/ interpretations 146 (33) Surgery advice 116 (27) ECMO-related 37 (8) Change in DX 12 (2.7) Starting from July 15th, Source: CHP ecicu Documentation database

25 e-cicu activities First consult diagnosis (7/2011 4/2012) ALCAPA TOF/PA, 6.1% 1.7% 0.6% 1.7% 1.1% 4.4% 0.6% 0.6% 0.6% 2.2% 0.6% 1.1% Atrial Flutter, 1.7% DCM, 3.3% Ao insufficiency Ao root dilation Ao stenosis Ao Pulmonary window Septic shock TOF, 4.4% 3.3% CAVC, 8.3% ASD Atrial Flutter DCM CAVC Coa Complete AVB CDH Corrected TGA TGA, 11.7% 2.8% 1.7% 0.6% DORV DILV Ebstein's anomaly of TV HLHS IAA 1.7% Kawasaki syndrome TAPVC, 5.0% 2.2% LCA occlusion MR PA/IVS 0.6% 3.3% 0.6% 0.6% 3.3% 0.6% 1.1% 4.4% 1.7% 0.6% IAA, 2.2% HLHS, 7.8% 0.6% PAH Paroxistic Tach Polysplenia Scimitar syndrome PDA Pertussis

26 Liver Transplant at CHP Two Models of Telemedicine Support Model A (ISMETT) Tele-ICU support for daily ICU tele-rounding among transplant team members of ISMETT and CHP Model B (FVL) Monthly case review (tele-pathology, case conference discussion) and annual site assessment

27 Model A (ISMETT): Preliminary Data 7 patients Patient Sex Diagnosis Transplant Significant Outcome complication 1. Male Biliary Atresia Split liver Arterial Died thrombosis, retransplantation 2. Male Hepatoblastoma Living donor - Alive 3. Male Cryptogenic Living donor - Alive Cholestasis 4. Male Biliary Atresia Split liver - Alive 5. Male Hepatoblastoma Split liver - Alive Patient and graft survival currently at 86%

Variable Pre-Telemedicine (n=38) Telemedicine (n=33) Median Age (years) 1.3 (0.9-4.2) 0.9 (0.7-2.4) Male Gender (%) 60 43 Median Body Weight (kg) 9.0 (7-15) 7.5 (6.

28 Variable Pre-Telemedicine (n=38) Telemedicine (n=33) Median Age (years) 1.3 ( ) 0.9 ( ) Male Gender (%) Median Body Weight (kg) 9.0 (7-15) 7.5 (6.7-10) <10 kg Weight (%) Median PELD Severity Score 15 (7-22) 12.5 (7-16) Diagnosis: Fulminant hepatitis (%) Biliary Atresia (%) Model B: FVL Survival at 2 years (%) <10 kg >10 Kg * 100*

29 ARCH INTERN MED/VOL 171 (NO. 6), MAR 28, 2011

30 Effect of telemedicine ICU coverage on ICU mortality ARCH INTERN MED/VOL 171 (NO. 6), MAR 28, 2011

31 Significant reduction in ICU lenght of stay ARCH INTERN MED/VOL 171 (NO. 6), MAR 28, 2011

32 Better Clinical Practice Guideline Adherence JAMA. 2011;305(21)

33 Location of Care after Hospital Discharge JAMA. 2011;305(21)

34 Significant lower mortality and shorter length of stay JAMA. 2011;305(21)

35 Future e-cicu Objectives International Electronic Cardiac Intensive Care Program To provide service in different countries all over the world Simulation program for Medical Education in Pediatric Cardiac Intensive Care Telemedicine-assisted QI in CICU

36 Education via Telemedicine Children s Hospital of Pittsburgh of UPMC

37 Medical education via Telemedicine - Simulation program Structured CICU scenarios with virtual patients Test/Evaluation before and after Simulation Knowledge/performance tracking Research 4 developed clinical simulation scenarios

38 Simulation video

39 International Telemedicine at CHP of Pittsburgh of UPMC Medellín Pittsburgh Bucaramanga Bergamo * (4700 ml) Cali Palermo (4735 ml) Mexico City * (1844 ml) Medellín (2379 ml) Bucaramanga (2343 ml) Cali (2565 ml)

40 CHALLENGES International legal boundaries Consent Remote licensing/credentialing Time difference Confidentiality and access to EMR Telemedicine team staffing Reimbursement

41 International laws Telemedicine consultation only by/with the presence of a nationally licensed physician e.g. EU, England, China, Russia, Israel, China, India Requirement of Consent Access to private information Privacy Liability Data protection

42 Conclusions International Telemedicine is feasible Telemedicine use is an option to overcome limited staffing in Pediatric Specialized Care Telemedicine may reduce mortality and length of stay in Critical Care Patients Further studies needed to demonstrate the effect of Telemedicine in morbidity, mortality & LOS

Terrence Lewis Associate Counsel, University of Pittsburgh Medical Center (Pittsburgh, Pennsylvania, USA)

Telemedicine, the Law and the Economics: A View from Both Sides of the Atlantic International Society for Telemedicine & e-health s Med-e-Tel 2014 Conference Terrence Lewis Associate Counsel, University