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Title and Description
CardioExpress Telemedical Services
Reviewed/ candidate case
Quality reviewed case
Short description
Founded in 1993 in Athens, Greece, CARDIOEXPRESS S.A introduced telemedicine services specializing in cardiology. Today, it is one of the largest European telemedicine companies providing service fortransmitting 8,000 trans-telephonic ECGs per annum.
Objectives and purpose
The company’s mission is to facilitate information and communications technologies (ICT) for providing real time telemedicine services in cardiology. Its services focus on the emergency care for elderly and those with chronic disease. The company’s services have effectively reduced patients’ delay in calling for help and obtaining diagnosis. It has also shortened the time until treatment could be delivered, resulting in reduced mortality rates following an AMI or other severe cardiac incidents.
Detailed description
In order to provide uninterruptible (i.e. 24X7) service, the company operates a modern call and control centre. The control centre is equipped with computer workstations allowing for the storage of electronic health records (EHR) and ECG analysis. It is staffed with a fully trained team of eight cardiologists who respond to all calls. The objective is to provide instant evaluation of each incident and suggest the best available treatment options. The service subscribers are equipped with a portable ECG that transmits 3-or 12- lead ECGs (by using standard telephone or mobile-phone or radio-telephone communication links) to the CARDIOEXPRESS call centre. All incident evaluations and their most appropriate treatment options are based on the specialists’ analysis and interpretation of one or more digital ECGs, as well as other clinical information available (e.g. blood pressure) and related symptoms provided verbally by the caller and entered into his EHR. In case of a diagnosing a cardiological problem that could be treated through self management, the appropriate care plan is defined, including medication. Alternatively, the company organizes to transport the patient through the National Emergency Servicesto an appropriate or proximal hospital. The company has entered into agreements with numerous hospitals in Greece as well as in other countries to facilitate such an arrangement. In such cases, communication between CARDIOEXPRESS and the hospital’s emergency departments takes place with a simultaneous transmission of relevant patient ECG data using the company’s SCP-ECG-compliant dedicated software., In addition Email communication is used for transmitting patient’s history and initial diagnosis. As a result, recipient organisations are better prepared for the management of the patient and delays in delivering appropriate treatment are reduced. Usually, data is not re-communicated from the hospital to the company. Calls from the subscribers to the control centre of CARDIOEXPRESS are automatically recorded as part of the increased security and auditing mechanism. Auditing is based on regular, internal discussions on the most difficult cases. CARDIOEXPRESS subscribers include large industrial facilities, sports clubs, hotels and elderly homes, shipping companies (merchant and passenger ships), rural primary healthcare centres, and medical practices (second opinion) that are spread over mountainous areas of Greece and the Greek islands. Also, a large number of individual subscribers include the elderly or those with chronic CVD. Services are also provided to the Greek Ministry of Defence. Due to constraints from the existing national legislation which prohibits advertisement of eHealth services, the company uses a door-to-door service promotion strategy and employs a regular service subscription model rather than a fee-for-service one.
Funding
The creation of the company was based on private funding (by its owners). Subsequently, the company has received financial assistance from the National Ministry of Economy through the Regional Development Funds (Subprogram Telematics Τ/221/29.3.94).
Interoperability and standards
The citizen’s EHR maintained and managed at the company’s call centre is based on the HL7 RIM. EU SCP-ECG standard is employed for the management and communication of digital ECGs. HL7 (v2.xx) messaging standards are used for achieving interoperability with the information systems of healthcare organisations. Currently, the usability of the DVB-RCS standard, rather than the traditional VSAT technologies used on most ships, is being piloted. The objective is to employ satellite communications for delivering bi-directional, broadband, IP-based services to rural and/or isolated areas and provide a better QoS for merchant ships around the world.
Timescale
Start of planning
1993
1st milestone
Service development and offering began in 1995 and the company has shown a steady rise, both in terms of subscribers as well as income.
2nd milestone
By the end of 2005, a critical mass of subscribers has been achieved and the company had installations in a number of remote and isolated institutional locations.
Start of routine operation
1995
Evaluation
Ongoing
Characteristic of the application
Country
Greece
Part in the healthcare chain
Diagnosis
Home-monitoring
Other
Level of Implementation
International
Technology
Bespoke/ locally build solutions
Details on Technology
Standards-based Electronic Health Record (EHR) application and protocol-based clinical response management guidelines are at the heart of the call centre’s IT infrastructure. PSDN and/or ISDN, 2.5G and/or 3G mobile and satellite based communications provide for connectivity to the site of emergency. The technological platform on the customer side is a small, hand-held unit. It utilizes a 9 volt PP3 type battery, providing battery life of 20 hours (equivalent to 1,500 transmissions). It is simple to use, resulting in minimal requirements for operator training and transmits 12 lead-ECG to the CARDIOEXPRESS Call Center within 42 seconds.
Results
Outcomes
- Citizens receive immediate diagnosis by specialists 24 hours a day (especially in case of cardiovascular events). - Doctors and other healthcare providers have the possibility to receive real time recorded ECG at the time of event. - Avoidance of unnecessary emergency transportation reduces costs for insurance companies and healthcare systems and works in their favour.
Wider impact
In general, the time lapse from the beginning of symptoms to delivery of hospital care yet remains high especially in acute cardiovascular events. This delay may be more than three hours, including transportation and waiting time in the hospital. The main problem, nevertheless, is the time lapsed until the patient calls for medical assistance (which can be as long as 60 minutes). At the individual level, service subscription has significant positive effects on the patient’s attitude as a result of extended training and education. The service is also contributing to the creation of a more informed and alert consumer. Specifically, CARDIOEXPRESS has succeeded to mobilize its subscribers to call immediately after the onset of symptoms and has achieved, on average, total time delay of 45 minutes, as against the best (recorded) result in Europe of 2.5 hours1 presented by Denmark. . Greece in general, has an average delay of more than 4 hours. On the healthcare system level, CARDIOEXPRESS services ease the burden on the hospital system, especially in the emergency units, and facilitate better and faster management of patients once they have arrived at the hospital.
Results expected?
In the domain of cardiology, the application’s outcome in terms of real time telemedicine services meets expectations.
Benefits in terms of increased access to care, reduced hospitalisation rates, reduction of unnecessary transportation costs (in many cases involving air transportation) have been observed.
Success factors
- Addressing patient needs along with assistance and involvement of other auxiliary actors (including healthcare professionals and the insurance company) is fundamental for success. - Pragmatic approach while responding to real needs: Step-by-step advancement, ensuring customer acceptance and agreement with other involved stakeholders, emphasis on uninterruptible service provision, comprehensive evaluation of benefits achieved. - Emphasis on training and customer empowerment. The company uses trained nursing staff that provides elaborate training (usually 6-8 hours) to its customers in using the technology, as well as providing accurate and proper information with respect to type and gravity of an emergency.
Failure factors
A major barrier to wider uptake (especially by individual citizens) is the fact that such eHealth services are non-reimbursable, and the subscription cost has to be borne by the individual. Other obstacles include:
- A major difficulty to persuade hospitals to participate in such a service delivery system. This task became easier once a critical mass of registered citizens was achieved.
- The existing legislation in Greece concerning health services prohibits advertisement in any form.
- Broadband (DSL) availability and use, although increasing, is not as prevalent as needed. As a result, QoS is not always optimal.
References
References and dissemination
Dissemination material and evaluation data can be found on the company’s website
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