CONGESTIVE HEART FAILURE ANNA POLYNIKI MDARISTOTLE ARISTOTLE

UNIVERSITY OF UNIVERSITY OF THESSALONIKITHESSALONIKI

SCHOOL OF SCHOOL OF MEDICINEMEDICINE

Professor:

Dr. Ernest Carter.

HOWARD UNIVERSITY

COLLEGE OF MEDICINE

Director:

Dr. Celia Maxwell.

INDEX1.INTRODUCTION

2.DEFINING TELEMEDICINE3.TELEMEDICINE APPLICATIONS

4.CONGESTIVE HEART FAILURE5.TELECARDIOLOGY IN CYPRUS

6.CONCLUSION

1.INTRODUCTION

2.DEFINING TELEMEDICINE

“Telemedicine is the use of electronic information and communication technologies to provide and support healthcare when distance separates the patient from the health care provider.”

1.TIMELY2.COST-EFFECTIVE

3.CONVENIENT ACCESS TO QUILITY HEALTH CARE

SERVICES ACROSS DISTANCE

ADVANTAGES OF TELEMEDICINE

1.Home health care for persons with chronic conditions

2.Transmission of diabetic patients’ glycose data from home

3.Transmission of ECG or EEG data4.Real-Time interactive orthopedic

examination and consultation5.Remote supervision of laparoscopic

surgical procedures6.Patient education

7.Diagnosis of an astronaut’s acute illness during space flight

3.TELEMEDICINE APPLICATIONS

4.CONGESTIVE HEART FAILURE

Heart failure is a complex syndrome that results from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump.It has a major impact on longevity and quality of life.One to two percent of the general population of developed countries have heart failure, and the average age at diagnosis is 76 years.Although the steady rise in hospital admissions for heart failure has slowed recently, the management of heart failure still accounts for 1-2% of healthcare expenditure in countries in the developed world.Improvements in cardiac imaging and new biochemical assays have made diagnosis more straightforward.Major changes in treatment have resulted from a better understanding of the pathophysiology of heart failure and the results of large clinical trials.Improving outcomes now increasingly depends on improved communication between healthcare professionals, education of patients and carers and better chronic disease management.

5.TELECARDIOLOGY IN CYPRUS

PREVALENCE OF CONGESTIVE HEART FAILURE IN CYPRUS

0,87%

Department Internal Medicine-

Cardiologist

Specialized Cardiologist

Nicosia 12 32

Limassol 15 15

Larnaca 4 10

Pafos 1 8

Ammochostos 1 2

Total 33 67

CYPRUS MAP

Daily

Every 6 weeks

Every 2 weeks

BPHR

WEIGHT

Chronic Cardiac Patients

Primary Health Care Center

Nurse

WORKFLOW

STABLE CONDITION

NOT STABLE3.Notifies nurse about

decisions

4.Nurse forwards patient doctor’s

orders

DETERIORATED CONDITION

STABLE CONDITION HOME

STABILIZED

CHANGE TREATMENT

1.Checks patient’s record2.Desides necessary follow-up

AMI

Cardiologist

WORKFLOW 1

SEVERE CHEST PAIN

PATIENT’S CONFERMATION PAGE

CONDUCTS CLINICAL

EXAMINATION

RECORDS A RESTING ECG

MYOCARDICAL ENZYMES

Primary Health Care

Center

WORKFLOW 2

1.Registration Information2.Administrative Data

3.Presenting Symptoms4.Diagnosis

5.Medication6.Specific Examinations

-ECG -ECHO cardiogram

-Laboratory Findings7.Demographics Page

PATIENT’S CONFIRMATION PAGE

DEMOGRAPHICS PAGEAnatomical Characteristics:

1.Ascending Aorta2.Aortic Arch3.Aortic Valve4.Left Atrium

5.Left Ventricle6.Mitral Valve

7.Interatrial Septum8.Interventricular Septum

9.Tricuspid Valve10.Right Atrium

11.Right Ventricle12.Pulmonary Artery

NO SUSPICION OF AMI

SUSPICION OF AMI

DEFINATELY AMI

STABILIZED HOME

REMOTE SITE

CONSULTANT SITE

2nd Interpretation of ECG is

Requested

ICU

Teleconsultation with a specialist cardiologist is

requested

DIAGNOSIS

TRF is constructed, reviewed and

signed

CENTRAL HOSPITAL

Specialist Cardiologist

PROCEDURE

1.Administrative Data2.Patient’s Demographics

3.Parts of Patient’s Medical History

4.Clinical Data -Blood Pressure -Laboratory Data

-Comments of Physician -Counter Indications for

Thrombolysis5.Sample Diagnosis

6.Treatment Plans for AMI

TELECONSULTATION REQUEST FORM

Insufficient Data

Requests Additional Data

1.Follow-up ECG2.Old ECGs

Reviews

NO AMI

SUSPICION OF AMI

Sufficient Data

NO AMI

SUSPICION OF AMI

STABILIZED HOME

TELEMEDICINE VISITPROCEDURE

A.SELECT MEDIALITY -Real-Time VideoTeleconferencing B.SCHEDULING -The patient -The local referring provider -The distant consultant provider C.EQUIPMENT SET-UP -Real-Time Consultation:Referring Site 1.The technician arrives at the bedside of the patient 2.Puts equipment in place, plags in power and telecommunications 3.Turns on and makes diagnostic peripherals ready for study 4.Starts software programs as needed 5.Checks: -peripherals as appropriate -cleans any patient-contact surfaces as needed 6.Dials consultant location for a test connection 7.Checks video quility 8.Checks audio quility and volume.Adjusts as needed 9.Checks “camera control” mode10.Hungs up test connection

PROCEDURE 1

-After patient is in place and ready11.Dials consultant location and establishes contact12.Caps video camera to ensure patient’s privacy-Real-Time Consultation:Consultant Site13.Puts equipment in place, plugs in power and telecommunications14.Turns on power for all equipment15.Starts softaware programs as needed16.Checks availability of medical information17.Accepts test connection call from referring site18.Checks video quility19.Checks audio quility and volume20.Checks “camera control” mode21.Hungs up test connectionD.PATIENT PREPERATION1.Patient orrientation checklist2.Explains patient about3.Reassures patient that4.Requests written informed consent5.Describes cost6.Introduces both send and receive people

•Telemedicine concept•Reason for using it•Participating peolple•The expected interactive experience

•Wont be on television•Quility of care will be appropriate and safe•Most patients are satisfied•Will have privacy and confidentiality

PROCEDURE 2

E.PROVIDER PREPERATION AT SEND/REFERRING SITE1.Assesses suitability of the patient2.Schedules patient3.Sends medical records of patient at Receive/Consultant Site4.Tests connections and peripheral devices5.Contacts consulting site to confirm readiness6.Completes patient’s orrientationF.PROVIDER PREPERATION AT RECEIVE/CONSULTANT SITE1.Confirms telemedicine visit is precisely scheduled2.Reviews medical records3.Receives test connect call from referring site.Checks audio/video settings4.Assures specialized cardiologist is available and located at receive stationG.REAL-TIME EXAMINATION1.Technician positions telemedicine stethoscope on patient’s chest as directed by the specialized cardiologist2.Technician establishes quility of sound3.Technician stores all heart sounds4.Technician positions ECHO transducer in the locations as directed by the specialized cardiologist

PROCEDURE 3

5.Technician establishes quility of image with each position6.Technician stores all video images by ECHO7.Technician records an ECG8.Ends telemedicine encounter-Specialized cardiologist approves images/sounds-All data is transferred to specialized cardiologist-Telecardiology consultation records become part of patient’s electronic health care record-Both parties sign off (linkage is broken)9.Telemedicine encounter ends-Specialized cardiologist reviews and generates consult-Diagnosis-Treatment plan

NO AMI

AMI

CONSULTATION IS SEND TO GP

Specialized cariologist advises the GP to give patient thrombolytic

treatment

Requests ambulance/helicopter to

transfer patient to Central Hospital

PROCEDURE 4

Patient is telemonitored so as the specialized

cardiologist will be alerted for possible arrythmias

ICU

CENTRAL HOSPITAL

TELEMONITORING

H.WRAP-UP1.Patient wrap-up-Patient is invited to ask any questions-Briefly assessment of patient’s comfort level and satisfaction2.Provider wrap-up-Briefly assessment of the telemedicine visit by providers of both sitesI.DOCUMENTATION1.Patient’s charts are maintained by both sites2.Stored images are maintained at the end site but not necessarily at the receive site3.Assure appropriate payment4.Assure insurance reimbursementG.EQUIPMENT SHUT DOWN/ CLEANING/ STORAGE1.Exit any computer-based applications and shut down the computer in an olderly manner2.Turn off power and unplug equipment3.Disconnect and properly store peripheral devices4.Clean all devices involving patient contact per infection control protocols5.Store equipment in a secure area or lock the examination room

PROCEDURE 5

GOAL

Enhancement Reliability of the

Telemedicine Systems

GOAL

MEDICAL PERIPHERALS

Operating System: MS Windows 95/98/NT 4.0/2000Processor: Pentium II - 300 MHz or higherRAM: 64 MB minimumSound Card(for use with Receive Software): Creative Labs SB Live! X-Gamer 5.1Creative Labs SB Live! MP3+ 5.1Creative Labs SB Live! Platinum 5.1Third Party Software Requirements (for IP transmission):E-mail:Outlook ExpressOutlook 97/98/2000Netscape 6Netscape Communicator 4.77Web Browser:Internet Explorer 4.0 or laterNetscape 6 or laterNetscape NavigatorNetscape Communicator 4.77 or laterSize: 26.4mm (1.04") H x 121mm (4.76") W x 201mm (7.91") L List Price : $2,995.00

Digital Electronic Stethoscope

Length: 7.10" (180MM) Width: 5" Height: 1.3" (33mm) Weight: 0.84 lbs. (.038kg) Power / Electrical: 4 AA alkaline batteries Intended Use: Resting Electrocardiogram Anatomical Sites: Non-invasive device, 12-lead electrocardiogram Safety Characteristics: Patient electrically isolated from mains.Patient leakage current <10uA Ground leakage current <50uA ECG Acquisition: Simultaneous 12-lead Patient Connection: 10-lead patient cable with RFI filter, defibrillator protection and patient isolation.Input impedence >100 MohmFrequency response 0.05-110 HzSensitivity: 5, 10, 20mm/mVADC resolution 2.44uV/bit Analysis & Measurement: Telemed Electrocardiogram

List Price : $3,990.00

ECG

CPU Hardware:

SmartProbe Connection: IEEE Standard 1394 - 6 pin (Firewire); In the Gateway, custom connection through the media bay.Processor: Pentium IIIProcessor Speed: 700 MgHz+Random Access Memory: 192 MB RAM minimum; (If running multiple diagnostic application on the same CPU, please consult AMD on RAM recommendations).Hard Drive: 10 GigabitRecommended Peripheral: Rewritable CD ROMSoftware:Microsoft Windows 2000 Professional

List Price : $26,000.00

Ultrasound

Dimensions: 2.63" (66.7mm) H x 6.45" (163.7mm) W x 4.37" (111mm) D Weight: Approximately 0.860 lbs. (390g) Type: Oscillometric Measurement Range: 20-280mmHG (BP); 40-200 beats/minute (Pulse) +3mmHG or 2%, whichever is greater (BP); +5% (Pulse) Display: Digital, character height: 0.63" (16mm) Pressurization: Automatic, using a micropump Depressurization: Constant-Air-Release Valve System Deflation: Automatic exhaust Power source: Four AA batteries (1.5V each) Battery Life: Approximately 3 months with one use/day Telephone Connection: RJ-11

List Price : $450.00

Digital Blood Pressure Monitor

General Examination Camera

Dimensions: 2.2"W x 3.7"D x 2.9"H Weight: .5 lbs.

Magnification: Auto-zoom from 1-50x. Polarization: Push-button

Zoom: Push-button Pixels: 410,000 from a 1/4" CCD

Horizontal Resolution: Greater than 430 lines

Signal to Noise Ratio: Greater than 48dB Output Signal: Composite and S-Video

Output Format: NTSC Integrated Freeze-frame: Push-button

Color Adjustments: Auto white balance ACC: Full iris control Lighting: Fluorescent

Operating Temperature Range: 0 degree C - 40 degree C

Operating Humidity: Less than 90% Power Consumption: 5W

Voltage Range: 110/220 VAC 10%, 50/60 Hz, or 12VDC

Lens: General purpose lens close focus, 50x polarized lens, and optional 200x polarized

contact lens

List Price : $5,490.00

Dimensions: 6.5"(16.5 cm) H x 8.6"(21.8 cm) W x 5.0"(12.7 cm) L

Weight: 6 lbs. (2.8 kg) Blood Pressure Accuracy: Meets or exceeds SP10-

1992 AAMI standards Cuff Pressure Range: 0-300 mmHg

Pressure Preset Levels: 120,140,160,200,240 or 280 mmHg

Systolic Determination: Max: 250 mmHg; Min: 60 mmHg

Diastolic Determination: Max: 160 mmHg; Min 30 mmHg

Pulse Rate Determination: Max: 200 bpm; Min: 40 bpm

Temperature Accuracy: Meets or exceeds ASTM E112-86 standards

Temperature Determination: Normal and Monitor Mode, Max: 108.0 deg. F (42.2 deg. C); Min: 84.0

deg. F (28.9 deg. C) Power Requirements: N. American version: 120

VAC, 60 Hz. International version: 220-240 VAC, 50-60 Hz

Internal Battery: Lead Acid, with external recharger

List Price : $ 2,995.00

Vital Signs Monitor

Telemedicine by definition involves a separation of distance and/or time between a patient and a diagnosing

physician.Some form of information is necessary to bridge the gap.And there are four primary modalities that are

used to carry out telemedicine: Phone and Fax, Store and Forward, Real Time Videoteleconferencing (VTC) and

Internet/Web-Based applications.  The telecommunication system chosen for this project is already existing and

proven.The major effort will be put on the integration of the various components and the software designed for

increasing the functionality of the telemedicine encounter which is dependent on the transmission of information

from one location to another.The list below includes the telecommunication technologies that will be included in

our telemedicine environment.

TELECOMMUNICATIONS

TELECOMMUNICATION TECHNOLOGIES

1.TELEPHONE2.FAX

3.INTERNET4.ELECTRONIC MEDICAL RECORD

5.PERIPHERAL EQUIPMENT CONNECTIONS6.BANDWIDTH

7.INTEGRATED PORTABLE DEVICE FOR TELEMEDICINE EMERGENCY

8.REAL TIME VTC9.TELEMEDICINE CONSULTATION

ROOM

FINANCIAL

PROFIT=GROSS REVENUE-EXPENCESA=REMOTE SITEB=CORPORATE EXPENCESC=CONSULTANT SITE

•EXPENCES=A+B+C•GROSS REVENUE-(A+C)=NET REVENUE•NET REVENUE-B=PROFIT•GROSS REVENUE ≥(A+B+C)+10%(A+C)•PROFIT=10% (A+C)

6.CONCLUSIONS

THE MEDICAL PROFESSION AND THE CHALLENGE

Telemedicine will be an integral part of Medicine in the forthcoming years.

• Distances between health care providers and patients will be eliminated.

• Health providers in a growing number of medical specialties, including, but not limited utilize Telemedicine: dermatology, oncology, radiology, surgery, cardiology, psychiatry and home health care.

• Cyprus, because of its small size, is not possible to have all the facilities to meet the health needs of the entire population, especially the needs in tertiary medicine therefore Telemedicine will be an essential element of the Medical Health Care System.

• Income>Expenditure.