Models for optimization of telecardiology services

Models for optimization of telecardiology services A.Kastania, S. Demarias, G. Loudos, E. Magos, J. Dimakopoulos, M. Paavonen, C. Davos, C. Boudoulas, S. Kossida Foundation for Biomedical Research of the Academy of Athens Bioinformatics Group Soranou Efesiou 4, 11527Athens, Greece

A telecardiology service includes: (i)real time transmission of electrocardiograms, (ii)transmission of cardiac images and patient data to provide help at distance from a specialized cardiologist in diagnosis and therapy of cardiac diseases (iii)provision of distance help in the therapy of patients who have emergency cardiac diseases (iv)information to the cardiologists who make the referral for the results of the tests (v)distant control and security of the biomedical devices

Tele-electrocardiography Tele-electrocardiography extends the capabilities of the acquisition machines of the electrocardiograms (ECG) to allow real-time transmission of electrocardiograms (ECGs) of a patient using a network to an expert cardiologist. At the expert cardiologist location two different policies can be applied: for the normal cases patient data can be automatically stored and for the abnormal cases patient data can be forwarded to a distant expert cardiological centre. Electrocardiogram (ECG) transmission Communication mode is real time. Patient vital data are transmitted. Transmission rate varies from 9.6 to 384 kbps. Typical networking architectures may be PSTN, GSM, ISDN or satellite. Equipment requirements include PC/modem, flatbed scanner, document camera and ECG device, or mobile phone and ECG device.

Tele-echocardiography Echocardiography is a precious diagnostic tool for cardiologists to determine problems of the valves of heart. The echocardiograms can be digitised at local places, transmitted for evaluation in a distant medical centre or hospital and stored using DICOM format in optical disks. Digital networks can be combined with portable devices, which can be used as extensions in the stethoscopes in order to transmit heart sounds.

Cardiac arrhythmias detection • Theexistingtechniquesusedtodetect cardiac arrhythmias are Holter, Rtestand telemetry.Real time monitoring andcontrolofcardiacarrhythmiasis feasible via provision of distant control services using ECG sensors. • When a cardiac arrhythmia is detected a message including the ECG signal and the related medical images of the patient (in the interior only) is send to the distant monitoring server. • The local system has a wireless sensor ECG and a local computer. The distant system has a central computer and a distant telemonitoring system (for diagnosis and image presentation).

Telecardiology using sensors

Mobile telemedicine units

The telecardiology systems can be classified by telephase and teleservice. The first indicates the medical moment the system is devoted to (e.g. prevention, diagnosis, therapy, treatment) and the second refers to the offered healthcare service (e.g. teleconsulting, telemonitoring, telereferral).

In recent years, several telecardiology applications have been successfully implemented over wired communication technologies like POTS, and ISDN. However, nowadays, modern wireless telecommunication means like the GSM and GPRS and the UMTS mobile telephony standards, as well as satellite communications, allow the operation of wireless telemedicine systems freeing the medical personnel and/or the subject monitored bounded to fixed locations.

Telecardiology platforms synthesis • Some medical devices allow extraction of an initial diagnosis for the electrocardiography signal that is stored within them, with various different interpretations and before its transmission to the distant expert. The various different users can use heterogeneous computing platforms via the DCOM model which provides the mechanisms for interoperability in computing environments with different operating systems, programming languages and network protocols.

Standards to design a telecardiology model A number of standards' solutions may be applicable on cardiologic biomedical devices. European standardization efforts in computer electrocardiography resulted to IEC 60601-2-51/AAMIEC 11 for safety and performance requirements and to the SCP-ECG, the Standard Communication Protocol for Computerized electrocardiography (CEN ENV 1064 AAMI EC71) used for the digital storage and transmission of ECG data.

Standards to design a telecardiology model The SCP-ECG is a rigorous standard that assures the complete information management. On the other hand, DICOM is a standard which allows to manage satisfactory all the types of cardiologic exams, in particular: for echocardiography DICOM image is used; for ECG and Holter the DICOM waveform is a possible selection and for pressure holter the DICOM SR (Structure Reported Documents) is a solution.

Standards to design a telecardiology model The IEEE 1073 is a standard for medical device communications that defines the entire seven layer communications requirements for the "Medical Information Bus" (MIB). The IEEE/MIB standards attempt to standardize physiological patient data and the HL-7 message protocol attempts to create a data interchange standard for the most common medical information managed by a hospital information system.

Α.Ν. Kastania, Telemedicine models for primary care.Stud Health Technol Inform. 2004;104:89-98.

Optimization of a telecardiology service incorporates quality and reliability assurance of telemetry. A telecardiology information system must guarantee the Quality of Services and the capability to collect and evaluate the results of telecare.

Drawing from a widely cited 1990 IOM report, the committee agreed that Quality of Care is "the degree to which health care services for individuals andpopulations increase the likelihood of desired health outcomes and areconsistent with current professional knowledge" (IOM 1990c, p. 21) TO BE MEASURED VIA QUESTIONNAIRES DESIGN

IN ADAPTATION PROCESS

IS QUALITY GOOD ENOUGH?

The steps for measuring software reliability are defined by the IEEE/ANSI Standard 982.2. • Software reliability can mean different things to different people in different situations. • Code must be reliable from the surprisingly divergent viewpoints of software developers, testers and users.

Extended study, evaluation and implementation of the previously mentioned models and standards is carried out in the Foundation for Biomedical Research, Academy of Athens in collaboration with Intracom and Netsmart in the framework of the Project «e-Hrofilos: a strategy for improvement of quality and reliability of Telecardiology» funded by the Regional Operational Program in Attica from National andEuropean Union Resources.

Models for optimization of telecardiology services A.Kastania, S. Demarias, G. Loudos, E. Magos, J. Dimakopoulos, M. Paavonen, C. Davos, C. Boudoulas,S. Kossida Foundation for Biomedical Research of the Academy of Athens Bioinformatics Group Soranou Efesiou 4, 11527Athens, Greece

Models for optimization of telecardiology services