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Telecardiology for patients with acute or chronic cardiaccomplaints: The ‘SHL’ experience in Israel and Germany

Arie Rotha, Harald Korbb, Ronen Gadotc, Eric Kalterd,∗

a Tel Aviv Sourasky Medical Center, Department of Cardiology, Tel Aviv, Israelb Personal Healthcare Telemedicine Services GmbH, Dusseldorf, Germanyc SHL-Telemedicine International LTD, Tel Aviv, Israeld Dutch Healthcare Insurance Board, P.O. Box 320, Diemen 1110 AH, Netherlands

a r t i c l e i n f o

Article history:

Received 30 September 2005

Received in revised form

21 April 2006

Accepted 21 April 2006

Keywords:

Telemedicine

Disease management

Heart failure, congestive

a b s t r a c t

Objective: To assess the impact of a telemedicine program in which electrocardiogram (EKG),

body weight and/or blood pressure are measured at home and medically trained personnel

judge the transmitted data and council the patients by telephone.

Method: We systematically studied the outcome and cost-effectiveness of the cardiac pro-

grams carried out by Shahal (SHL) during the past 19 years.

Result: Most patients (85%) with acute complaints resembling coronary artery disease, could

be reassured, representing a savings of about D 677.000 per 10,000 members/yr in Israel in

1989, and a marked reduction in patient delay to 44 min (median). In chronic heart failure a

66% reduction in hospitalisation days was observed, together with an improvement in qual-

ity of life. A large Healthcare Insurance Company in Germany (Taunus BKK) has calculated

that it can save at least D 5 million per year with the use of such services.

Coronary disease

Myocardial infarction

Conclusion: Disease management with concomitant telemedicine for coronary artery disease

and chronic heart failure is safe and effective and has a huge potential for cost savings,

ity of life and in prognosis of heart disease.

improvements in qual

1. Introduction

The increase in elderly and chronically ill patients will posean increasing burden on the capacity and financing of thehealthcare systems in western countries. To overcome theseproblems it is mandatory to install disease management pro-grams with the aid of telemedicine [1]. Disease manage-ment is a system of coordinated healthcare interventions andcommunications for populations with conditions in whichpatient self-care efforts are significant [2]. Disease manage-

ment supports the physician or practitioner/patient relation-ship, emphasizes prevention of exacerbations and complica-tions utilizing evidence-based practice guidelines and patientempowerment strategies with the goal of improving overall

∗ Corresponding author. Tel.: +31 615028960.E-mail address: ekalter@cvz.nl (E. Kalter).

1386-5056/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights resdoi:10.1016/j.ijmedinf.2006.04.004

© 2006 Elsevier Ireland Ltd. All rights reserved.

health. Personal telemedicine is the transmission of medicaldata via telecommunication networks by an individual patientfrom a remote location to a medical call center for the purposeof monitoring, diagnosis, and patient and disease manage-ment. It increases quality of care at lower costs and enhancespatient education and compliance. On the basis of frequentmonitoring in the home situation, decreases in the condi-tion of the patient can be detected early, thus enabling timelyinterventions by dedicated medical personnel. It not only pro-vides the patient with a higher level of safety and quality

of life, but also decreases the workload of the medical sup-port systems. Finally, telemedicine truly enables the patientto make the transition to demand-driven care. This articlefocuses on the application of disease management programs

erved.

i c a l

644 i n t e r n a t i o n a l j o u r n a l o f m e d

with a telemedicine component for cardiovascular diseasesi.e. acute coronary syndromes and chronic heart failure withremote monitoring of vital parameters in the home situation.

2. Method

We systematically studied the outcome and cost-effectivenessof the cardiac programs as carried out by the internation-ally operating telemedicine-services provider SHL (Shahal,http://www.shl-telemedicine.com/) and report in this articlean interpretive review of the results obtained within the past19 years. It is the goal of SHL to offer (1) the patient with (fear of)coronary artery disease reassurance or (acute) interventionsin case of complaints or emergency through the assistance bywell trained medical personnel, available during 7 × 24 h at aremote monitoring centre, or at the patients home, after dis-patch of an ambulance and (2) the patient with chronic heartfailure a totally integrated, protocol-driven, pro-active care.

3. Results

3.1. Coronary artery disease

Coronary artery disease gives rise to episodes of acute chestpain, which may or may not result in acute myocardial infarc-tion. Already in 1995 interesting observations have been pub-lished from the telemedicine service program of SHL withpatients who were trained to use a device for trans-telephonictransmission of an electrocardiogram (EKG) in case of acutecomplaints [3]. It could be proven that the time elapsedbetween onset of cardiac symptoms and the decision to callfor medical help was markedly shortened to 44 min (median)and that in the majority of calls an emergency pick up by anambulance could be avoided and thus a fair number of emer-gency room visits too. Therefore the SHL experience provedto be a double edged sword, reassuring most (85%) of thepatients calling in, and helping those truly in need faster (15%)whilst avoiding unnecessary involvement of medical attentionat emergency rooms. Too many patients with a heart attackare still waiting too long before calling for medical assistance,which is crucial for survival and prognosis [4]. In order to illus-trate the cost saving potential of this approach, a randomlyselected group of subscribers (n = 1870) to the telemedicineservice of SHL in Israel, who had called in for medical assis-tance during the previous 24 h, were asked what action theywould have taken had they not been SHL subscribers [5]. Ofthese, the answers of 1608 subscribers (age 71 ± 13 (S.D.) years)could be included in the analysis: 514 replied that they “wouldhave waited”, 363 “would have contacted their physicians”,and 731 “would have sought emergency department care.”A cost estimate indicated that the service resulted in a sav-ings to the national economy of Israel of approximately D677.000 per 10.000 members/year, in 1989. This study demon-strated that SHL membership can reduce costs of medical care

and the number of hospital emergency department visits. Ina subsequent study it could be shown that the use of bloodtests at home by a mobile ICU team was able to pinpoint thepatient in danger even more precisely when the physician

i n f o r m a t i c s 7 5 ( 2 0 0 6 ) 643–645

was in doubt about the diagnosis Acute Myocardial Infarction(AMI), to rule out ischemic events, 6–48 h after onset of com-plaints [6]. Recently the clinical reliability of telephonic trans-mission of the EKG was validated, in 70 consecutive patientswith acute coronary syndrome and elevated cardiac markersadmitted to the cardiac care unit of the University Hospitalof Aachen (Germany) [7]. At admission an EKG was recordedby a standard 12-lead EKG device. In parallel an EKG wasalso recorded by a small and portable unit, capable of trans-mitting 12-lead EKG’s via a standard telephone line, and thiswas transmitted to the call centre of the Personal HealthCareTelemedicine Services GmbH (PHTS), a fully owned subsidiaryof SHL at Dusseldorf (Germany). In a retrospective analysis,each lead of the transmitted EKG was compared with the on-site 12-lead EKG with regard to ST-segment changes and finaldiagnosis. In all 37 patients with AMI and acute ST elevationon the EKG, this diagnosis was also correctly established onthe basis of telephone-transmitted EKG’s. In the remaining 33patients with documented AMI, no new or presumed new ST-segment elevations were present at admission on the standard12-lead EKG and, by the same token, no such ST-segment ele-vations were observed either at analysis of EKG, transmittedby telephone to the monitoring centre. A control group of 31patients without apparent heart disease showed high concor-dance between standard EKGs and telephonically transmittedEKGs. The authors conclude that: ’telephonically transmitted12-lead EKGs [. . .] might allow a rapid and accurate diagnosis ofST-elevation myocardial infarction and may increase diagnos-tic safety for the emergency staff during pre-hospital decisionmaking and treatment of acute myocardial infarction’.

3.2. Chronic heart failure

Chronic heart failure (CHF) is a typical example of a chronicdisease that qualifies for a disease management program withtelemedicine support and self-monitoring at the home sit-uation. It is estimated to affect about 2% of the populationand is characterized by acute episodes of shortness of breath,due to fluid overload. In 1997, it was reported that intensivecontact by telephone, on the basis of consensus guidelineswas able to increase patient compliance to therapy and toreduce emergency room visits for heart failure by 67% andhospitalisation rates by 87% [8]. Thereafter several studiesdemonstrated fewer hospitalisations and fewer total days ofhospitalisation by implementing homecare strategies [9–13].In 2001, a pilot study was published in which 10 patientswith CHF were monitored with fully automated data trans-mission of blood pressure, heart rate and weight, to a centralserver, proving that this concept could work in daily prac-tice [14]. Recently, Roth ea. published a larger series of 118patients with CHF, who’s blood pressure, heart rate and weightwere transmitted automatically to a medical service centre ofSHL, to be monitored with the aid of a software algorithm,in conjunction with a 24 h emergency call service on demandin case of medical complaints, and an elective biweekly callfrom nursing staff to promote adherence to therapy [15]. When

comparing data with those obtained retrospectively from thesame group during the preceding year, a 66% reduction inhospitalisation days was observed, together with an improve-ment in reported quality of life. Meanwhile, this program has

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[18] M. Schoone, J.A.M. van Boxsel, Kansen voor technologische

i n t e r n a t i o n a l j o u r n a l o f m e d i c a

aken off in Germany, where a telemonitoring service centreas been established at Dusseldorf. In this centre, compara-le results are obtained. The Healthcare Insurance Company

Taunus Betriebskrankenkasse’ (http://www.bkk.de/) has cal-ulated that it may generate a net savings of at least D 4.7illion per year on various medical and related costs with

he use of such services for their members [16,17]. From anconomic point of view the use of telemedicine has recentlyeen recommended as one of the possible options to increase

abour-productivity in healthcare in The Netherlands [18].

. Conclusion

e conclude that a longstanding experience has beenuilt up by SHL in disease management with concomitantelemedicine for coronary artery disease and chronic heartailure, that it has been proven to be safe and effective andhat it has a huge potential for cost saving, improvements inuality of life and in prognosis of heart disease.

e f e r e n c e s

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[14] S. de Lusignan, S. Wells, P. Johnson, K. Meredith, E.Leatham, Compliance and effectiveness of 1 year’s hometelemonitoring. The report of a pilot study of patients withchronic heart failure, Eur. J. Heart Fail. 3 (2001) 723–730.

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[16] Neuer Vertrag deckt Telemedizin fur chronisch Herzkrankeab. Arzte Zeitung, 23.03.2005 http://www.aerztezeitung.de/docs/2005/03/23/053a0501.asp?cat= (April 16 2006).

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