available Management decisions based on incomplete or delayed diagnostic information may result in morbidity and mortality or unnecessary transfers Randolph et al reported that using telemedicine resulted in a complete diagnosis for 132 of 133 patients (99%) with suspected congenital heart disease Patient transfer was recommended or avoided in seven patients, an immediate change in local medical management occurred in an additional 25 of 133 neonatal patients (19%), and congenital heart disease not requiring immediate treatment was noted in 47 infants (35%).17 Table 91.1 History of Pediatric/Congenital Tele-Echocardiography Publications Study Finley11,63,138 Sobczyk12 Fisher2,3 Casey15,139–141 Rendina18,19,142 Houston4 Randolph17 Sable6 Scholz14,143 Sable7 Sharma27 Widmer144 Munir145 Sahn146 Woodson8 Castela147 Lewin13 Awadallah16 Sekar148 Koustic107 Gomes62 McCrossan34,149 Location Year(s) Nova Scotia 1989, 1997, 2004 Kentucky 1993 Chicago 1996 Ireland 1996, 1998, 2008 North 1997, Carolina 1998 Glasgow 1999 Minnesota 1999 New 1999 Orleans Iowa 1999, 2001 Washington, 2002 DC New York 2003 Switzerland 2003 Hawaii 2004 Portland 2004 Washington, 2004 DC Portugal 2005 Seattle 2006 South 2006 Dakota India 2007 London 2007 Portugal 2010 Ireland 2011, Key Findings Real time over POTS, cost savings, tele-education Store and forward over POTS Real time over single ISDN line Real time over low bandwidth connection Outcomes and reduced length of stay 100% accuracy requires 3 ISDN lines Accuracy, management over T1 Accuracy, proficiency, cost savings over 3 ISDN lines Minimal difference: cardiologist vs pediatrician ordering echo in children less than one year of age 500 studies/3 ISDN lines/impact on practice Efficacy of fetal tele-echocardiography Real time over 3 ISDN lines/feasibility and accuracy Live and store and forward between Hawaii and Guam Remote real time image control and optimization Forward and store tele-echocardiography 1761 consultations over 5 years/mostly elective 769 studies/3 ISDN lines/99% accurate Neonatal tele-echocardiography triage Real time/small aperture satellite bandwidth Belgrade to London conference over single ISDN line Fetal, neonatal, and pediatric consultations in real time Fetal tele-echo accuracy and skill transfer Haley150 Dehghani151 Webb22 Krishan21 2012 Arizona 2012 Canada 2013 US (9 sites) 2013 Washington, 2014 DC Real time telemedicine more accurate than recorded echocardiograms Videoconferencing for ACHD management Multicenter prospective case-control study: tele-echo decreases transports, length of stay, and high-risk medications Technology transition, >10,000 studies/15 years ACHD, Adult with congenital heart disease; ISDN, integrated services digital network; POTS, plain old telephone systems; T1, Terrestrial 1 From Satou GM, Rheuban K, Alverson D, et al Telemedicine in pediatric cardiology: a scientific statement from the American Heart Association Circulation 2017;135(11):e648–e748 Rendina et al reported a reduction in length of stay of 5.4 days in a level III North Carolina neonatal intensive care unit in the first 6 months of their study compared to the 6 months prior without telemedicine.18,19 The cost attributable to telemedicine in their model was $33 per echocardiogram They projected that cost savings over a 1-year period would be $1.3 million Additional monetary benefits of telemedicine that are more difficult to quantify include cost savings from prevention of delayed or incorrect management, and avoidance of the financial burden of travel and lost wages for the patient's family.20 In a study of 500 echocardiograms in the Washington, DC, metro area, comparison of final videotape interpretation to initial telemedicine diagnosis resulted in only one minor diagnostic change (membranous vs inlet ventricular septal defect), and telemedicine had an immediate impact on patient care in 151 studies.7 We reported on our technology transition experience of over 10,000 telemedicine transmissions from 24 sites in seven states and territories between 1998 and 2014.21 A significant increase in telecardiology utilization took place after IP expansion without detrimental effects on efficiency or diagnostic accuracy This occurred in parallel to a change from a predominance of real-time telemedicine to store and forward transmissions Over 150 patients were transported for surgical, catheter-based, or medical intervention, and critical heart disease was ruled out in over 75 patients, preventing unnecessary transport Medical management and/or outpatient follow-up was recommended in approximately half of the studies for minor heart defects A multicenter study from nine centers assessed the impact of telemedicine on infants with either no or minor heart disease The authors identified 338 pairs of infants with and without access to telemedicine, and were matched for study indication, diagnosis, gestational age, birth weight, and gender.22 Access to telemedicine resulted in statistically significant reductions in rate of transfer to a tertiary care hospital (10% vs 5%), total and intensive care unit length of stay, and inappropriate use of inotropic support and indomethacin (Tables 91.2 and 91.3) Table 91.2 Length of Stay From a Multicenter Study Telemedicine INCLUDING OUTLIERSa Total length of stay Length of ICU stay EXCLUDING OUTLIERSa Total length of stay Length of ICU stay Control P Value 1.0 ± 6.8 days Range: 0–102 days 0.96 ± 6.8 days Range: 0–102 days 2.6 ± 11 days Range: 0–96 days 2.5 ± 11 days Range: 0–96 days 005 0.72 ± 4.1 days Range: 0–44 days 0.65 ± 4.0 days Range: 0–44 days 1.6 ± 6.4 days Range: 0–58 days 1.6 ± 6.2 days Range: 0–58 days 027 024 026 a Greater than 60 days ICU, Intensive care unit From Webb CL, Waugh CL, Grigsby J, et al Impact of telemedicine on hospital transport, length of stay, and medical outcomes in infants with suspected heart disease: a multicenter study J Am Soc Echocardiogr 2013;26(9):1090–1010 Table 91.3 Medical Complications/Interventions From a Multicenter Study Inotropic support Indomethacina Prostaglandin E1 Mechanical ventilation Extracorporeal membrane oxygenation Intraventricular hemorrhage Cardiac arrest Death Telemedicine 8% (n = 27) 11% (n = 29) 0% (n = 0) 28% (n = 94) 1% (n = 2) 7% (n = 24) 2% (n = 6) 4% (n = 13) Control 26% (n = 88) 18% (n = 47)