Diagnosis from a Distance: Telecardiology in the Evaluation of Fetal Arrhythmias
J. Fred Thomas
Christina A. Olson
Gerard Frunzi
Bettina F. Cuneo
INTRODUCTION
There are several reasons that a timely and accurate diagnosis of a fetal arrhythmia is beneficial to the fetus and to the pregnancy. First, diagnosis sets the stage for appropriate care. Second, risk stratifying fetal arrhythmias efficiently utilizes healthcare resources.1,2 Third, after the diagnosis is made, the parents can consult with the physician to develop a care plan, which can reduce stress and anxiety.3
However, fetal arrhythmia expertise is usually concentrated in cardiac centers, often many miles from the pregnant woman’s home. In the absence of this expertise, initial triage of fetuses with arrhythmias is performed by obstetricians, family physicians, or mid-wives (“OB providers”) in the local community. One solution to expand access to limited but necessary expertise is by partnering OB providers from the local community with fetal cardiologists at a distant cardiac center through a form of telemedicine we call “fetal telecardiology.” Fetal telecardiology is the real-time performance of fetal echocardiograms at the local community site with a face-to-face virtual interpretation, diagnosis, and consultation by fetal cardiologists at the distant cardiac center.
Such a partnership between OB providers in the local community and fetal cardiologists at the distant cardiac center is possible due to recent advancements in telecommunication technologies including the digital transmission of objective data blended with video conferencing software. Telemedicine has reduced cost, increased efficiency, improved quality, and expanded patient access to subspecialists in some areas of medicine, including obstetrics.4,5,6,7,8,9,10,11,12,13,14 Fetal teleECHO for identification of structural heart disease during screening echocardiograms has been described,15,16,17 but there are few data on the use of fetal telecardiology in the evaluation and management of fetal arrhythmias.
This chapter will describe the results of one fetal telecardiology program, the necessary resources needed to develop such a program, and the real and potential impact on providers, patients, and the healthcare system.
DEVELOPMENT OF A FETAL TELECARDIOLOGY PROGRAM
Feasibility
The feasibility of a fetal telecardiology program is strongly dependent on several factors. First, OB providers in the community must understand and desire the benefits of such a program for their patients and themselves, the latter in the form of continued education and practice quality improvement. Second, a respectful and collaborative relationship between fetal cardiologists in the distant cardiac center and OB providers in the community needs to be established and nurtured; without this effort, employing fancy technology and equipment has little value. Third, OB sonographers in the community must be comfortable scanning fetal hearts independently with virtual coaching and guidance. Fourth, the fetal cardiologist must be committed to providing care “on demand,” outside of regular clinic hours, as some fetal arrhythmias require urgent evaluation. Fifth, telemedicine technical support is necessary at the distant and community sites to prevent interruption of services. Sixth, in many cases, the fetal cardiologist must be comfortable with teaching and supervising OB sonographers rather than pediatric echo technicians. Lastly, the health system administrators, physicians, and providers at both the community and distant cardiac center must be aligned and agree on long-term goals, such as improving fetal cardiology productivity, expanding clinical coverage across the region, and increasing clinical capacity of the cardiac center.
Aims
The key aims of a comprehensive fetal telecardiology program are to:
Advance the education and training of local OB sonographers in fetal cardiac imaging and arrhythmia ascertainment.
Increase the access, efficiency, and process of care for the patients needing these services.
Demonstrate that this new and innovative care model has the same diagnostic quality as face-to-face encounters.
Determine that fetal telecardiology is accepted and even preferable by mothers and their OB providers in the community.
Education and Training of Sonographers
Expertise and experience in fetal anatomic surveys provide a good background for training in fetal arrhythmia diagnosis. The training period for OB sonographers already competent in fetal scans is usually 3 to 6 months. Training begins with implementing standard fetal echocardiography protocols under the supervision of experienced fetal echo sonographers and fetal cardiologists at the distant cardiac center. Once protocols are firmly established, the OB sonographers observe images of fetal rhythm abnormalities. Lastly, the sonographer applies the echo protocol to systematically evaluate fetuses with arrhythmias. Most of training occurs at the cardiac center, but skills are
reinforced by repetitive in-person instruction by the fetal cardiologist working with the OB sonographers at the community hospital. The importance of in-depth, multisession training cannot be understated, as high-quality rhythm assessment by the sonographer is critical for appropriate diagnosis and treatment.
reinforced by repetitive in-person instruction by the fetal cardiologist working with the OB sonographers at the community hospital. The importance of in-depth, multisession training cannot be understated, as high-quality rhythm assessment by the sonographer is critical for appropriate diagnosis and treatment.
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