Diagnosis Goes the Distance

Virtual clinics extend diagnostic services to remote areas

Erik “Rick” Michelfelder, MD conducts many of his clinic duties from behind his desk. 

Michelfelder, director of the Fetal Cardiac Program at Cincinnati Children’s, sees patients  hundreds of miles away by dialing into a link that is part teleconference, part Skype.

A window on Michelfelder’s computer shows an ultrasound happening live. He watches and can direct a sonographer at Cabell Huntington Hospital in West Virginia to zero in on particular areas during a fetal echocardiogram.

On the other end of the connection, the obstetrician, sonographer and pregnant patient can see and hear Michelfelder on a computer monitor as he examines images of the baby’s heart.

The scenario is an example of how Cincinnati Children’s is extending its diagnostic services to places such as the middle of Appalachia, where a large proportion of the population does not have access to this kind of specialized care.

“We are trying to make detailed diagnoses when the heart is sometimes not a whole lot longer than an inch in length,” Michelfelder says. “I can look at the fetal echocardiogram as it is happening and actually talk to the mother about the results before she leaves the room.”

Cincinnati Children’s has seen more than 300 fetal cases this way since 2006, and that list is growing by about 10 patients a month in the fetal area alone through this twice-monthly virtual clinic.

We’ve now been approached about doing this in Buffalo, NY, in Anchorage, AK, and in Sioux Falls, SD, to assist these centers that may be underserved with particular expertise,” says Tim Crombleholme, MD, FACS, FAAP, director of the Fetal Care Center of Cincinnati and director of the Center for Molecular Fetal Therapy at Cincinnati Children’s.

Crombleholme sees tele-echocardiography as a way for Cincinnati Children’s and a team of nearly a dozen echo physicians to have an impact in patient care beyond the Cincinnati area.

“It’s in keeping with our mission to be the leader in child health throughout the world, and you don’t do that just by operations in Cincinnati,” he says. “You have to raise the bar everywhere.”

A skilled eye

Almost any American hospital these days uses ultrasound as one of the most reliable tools for visualizing the heart in a safe, noninvasive way.

But it takes a specialist to be able to look at images from that tool and make a skilled diagnosis.

Thomas Kimball, MD, director of echocardiography at Cincinnati Children’s, also works with Cabell Huntington Hospital to be an extra set of eyes when a baby is born with possible heart disease.

As the only pediatric cardiologist at Cabell Huntington, Mahmood Heydarian, MD, could never find the time to travel or attend conferences because people depended on him to read scans for critical patients.

This relationship with Cincinnati Children’s allows him some flexibility. If he is out of town or needs a consultation or second opinion, Kimball or another specialist here can step in and look at an echo of a baby’s heart.

“It’s extremely helpful,” Heydarian says. “You are one telephone call away from answers. We really appreciate the input.”

It’s making a difference for technicians as well, says Romaine Perdue, the electrocardiography/echocardiography supervisor at Cabell Huntington.

“For me, it has been educational, even though I’ve been doing echo for 34 years,” she says. “I feel a lot more confident because all of the weight isn’t on my shoulders. I know I am going to be able to talk to people who know what to do.”

Before this, Perdue says, Cabell Huntington would have automatically transported the patient.

Better patient care

For echocardiography specialists at Cincinnati Children’s, helping doctors manage patients in Appalachia is just the beginning.

“We are providing tertiary care expertise for patients who up till now would have no way to access it,” Kimball says. “We can immediately tell the remote location to start treatment A, B and C and facilitate transport. We’re expediting care, intervening way earlier than would happen normally, and helping to potentially save babies’ lives.”

Electronic diagnostics also help the doctors manage babies closer to home, including some of those born at Cincinnati birthing centers such as Good Samaritan.

“It’s a big delivery center where a lot of babies are born with suspected heart problems,” Kimball says. “Until now, babies had to be transported here to get an echocardiogram. Now we can use this to better manage where the babies go.”

Remote echoes can save unnecessary transport of fragile babies and allow for better patient management if transport is needed, says Kimball, who expects the web-based program to grow even more.

“It can happen in a rural area. It can happen at a hospital across the street,” he says. “There’s no reason it can’t happen internationally.”