of pediatric cardiology systems into a single telemedicine system and corporate partner, a unified data collection protocol, and a shared model of data access.117 The National Pediatric Cardiology Quality Improvement Collaborative (NPCQIC) has focused on reduction of interstage morbidity and mortality for single ventricle patients after stage I palliation.118–122 This program includes home surveillance of pulse oximetry, weight, nutritional intake, and warning signs of deterioration.115,123,124 One of the consistent findings from the NPC-QIC is the importance of weight gain on positive outcomes This is consistent with a report by Ghanayem et al from Children's Hospital of Wisconsin, that initiation of a program that recorded daily weight and oxygen saturation at home improved survival in patients with hypoplastic left heart115 and played a critical role in determining the ideal timing of bidirectional Glenn.125 Cross et al reported utilization of a telemedicine solution for interstage single ventricle care that incorporated automated transmission of pulse oximetry, weight, and formula intake, along with answering questions about the status of the infant.126 This solution included a website with automated warning alerts and a patient dashboard for easy access to subtle changes over time The weight-for-age percentile for patients with access to home telemedicine was more likely to increase than in those patients without access to home telemedicine Take, for example, patient W.L., who was born with hypoplastic left heart syndrome and underwent stage I palliation with Norwood reconstruction of the aortic arch and right modified Blalock-Taussig shunt His postoperative recovery was mostly uneventful and he was discharged home around 3 weeks of age A month later he appeared to be less playful than usual but no other concerns Even though they lived about 200 miles away, the family knew that they could have instant access to pediatric cardiology services through the hospital-provided tablet computer They took a 30-second video of their son's breathing and obtained heart rate and pulse oximetry numbers, which were then quickly transmitted to a cloud-based server His heart center staff got an instant pager notification They astutely noted subtle increase in rate and work of breathing and arranged for hospital admission An echocardiogram in the emergency room confirmed development of coarctation of the reconstructed aortic arch, which was treated with balloon angioplasty and resulted in symptomatic relief and possible prevention of death Global Telemedicine Less than 10% of the world's population has access to life-saving surgical and catheter-based interventions to treat even low-risk congenital heart defects,127 and rheumatic heart disease remains endemic across most of the globe.128 Collaboration between cardiology and cardiac surgery experts in high-income countries and programs in low- and lower middle-income countries is essential to close this gap in care Telemedicine can be a very powerful tool to facilitate care and disease prevention in low- and middle-income countries.129 Educational web conferences can have a significant impact on improving outcomes for congenital heart surgery in resource-poor countries.130 Live patient care conferences and sharing of images via cloud imaging can advance research collaboration for congenital and rheumatic heart disease.131,132 We recently reported on using telemedicine to facilitate screening of over 4000 Brazilian children for rheumatic heart disease.133 Echocardiograms performed in schools in Brazil were uploaded to the cloud and interpreted jointly by physicians in Belo Horizonte, Brazil, and Washington, DC There are, however, several challenges to successful implementation of global telemedicine programs These include differences in time zone, language, culture, local government regulations, Internet security, maintenance of equipment, and lack of access to affordable broadband connectivity, especially in more remote regions Cloud Computing Cloud computing and telemedicine expertise is now also commercially available Instead of on-site data storage, vendors like GE ViosWorks provide cloud computing, flexible storage, and complete analysis services on a pay-per-use basis Using this approach, the hospitals can save on human resources, and purchase and maintenance of specialized software for cardiovascular image analysis, such as to assess myocardial iron overload, MRI four-dimensional (4D), flow, and fractional flow reserve Vendors ensure patient privacy and data security by working with deidentified data while the identifiers stay at the source hospital Cardiovascular imaging experts are saying that if patient privacy and data security are guaranteed, cloud-based expert telemedicine care is a valuable option, especially to offer sophisticated cardiovascular image analysis such as computational fluid dynamic modeling and 4D flow for all institutions.134 There is mounting literature on this form of telemedicine suggesting that image data can be obtained in a fraction of the time when using cloud-based distributed computing reconstruction Cross et al reported 37% reduction in acquisition and reconstruction time for MRI ventriculometry.135 Chelu and colleagues, using 4D flow imaging postprocessed with an integrated cloud-based application, accurately quantified pulmonary flow when compared to traditional phase contrast flow measurements.136 To leverage cloud-based telemedicine, the Gadgetron is an open-source framework for medical image reconstruction that has been developed at the National Heart, Lung, and Blood Institute and at the Department of Computer Science and Department of Clinical Medicine, Aarhus University, Denmark.137 It is made freely available to the medical image reconstruction community It is foreseeable that institutions will utilize Gadgetron-like tools to provide cloud-based telemedicine in a scalable way to improve image reconstruction and quantification of data Time and expertise are extremely valuable resources within the healthcare industry, as care providers are on a constant run to serve their patients efficiently Telemedicine outsourcing of care and service providers is no new phenomenon to pediatric cardiology However, cloud delivery of medical data has evolved to be the most economic and effective solution With all the telemedicine services, legacy applications, obsolete technology protocols, and influx of smart Internet of things devices within the hospital, ransomware threat has become a reality ... industry, as care providers are on a constant run to serve their patients efficiently Telemedicine outsourcing of care and service providers is no new phenomenon to pediatric cardiology However, cloud delivery of medical data has evolved to be the most economic and effective solution... and rheumatic heart disease remains endemic across most of the globe.128 Collaboration between cardiology and cardiac surgery experts in high-income countries and programs in low- and lower middle-income countries is essential