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1.  Mobile, Cloud, and Big Data Computing: Contributions, Challenges, and New Directions in Telecardiology 
Many studies have indicated that computing technology can enable off-site cardiologists to read patients’ electrocardiograph (ECG), echocardiography (ECHO), and relevant images via smart phones during pre-hospital, in-hospital, and post-hospital teleconsultation, which not only identifies emergency cases in need of immediate treatment, but also prevents the unnecessary re-hospitalizations. Meanwhile, several studies have combined cloud computing and mobile computing to facilitate better storage, delivery, retrieval, and management of medical files for telecardiology. In the future, the aggregated ECG and images from hospitals worldwide will become big data, which should be used to develop an e-consultation program helping on-site practitioners deliver appropriate treatment. With information technology, real-time tele-consultation and tele-diagnosis of ECG and images can be practiced via an e-platform for clinical, research, and educational purposes. While being devoted to promote the application of information technology onto telecardiology, we need to resolve several issues: (1) data confidentiality in the cloud, (2) data interoperability among hospitals, and (3) network latency and accessibility. If these challenges are overcome, tele-consultation will be ubiquitous, easy to perform, inexpensive, and beneficial. Most importantly, these services will increase global collaboration and advance clinical practice, education, and scientific research in cardiology.
doi:10.3390/ijerph10116131
PMCID: PMC3863891  PMID: 24232290
mobile computing; cloud computing; telecardiology; electrocardiograph; echocardiography; medical images; big data
2.  The Clinical Application of a PACS-Dependent 12-Lead ECG and Image Information System in E-Medicine and Telemedicine 
Journal of Digital Imaging  2009;23(4):501-513.
This study presents a software technology to transform paper-based 12-lead electrocardiography (ECG) examination into (1) 12-lead ECG electronic diagnoses (e-diagnoses) and (2) mobile diagnoses (m-diagnoses) in emergency telemedicine. While Digital Imaging and Communications in Medicine (DICOM)-based images are commonly used in hospitals, the development of computerized 12-lead ECG is impeded by heterogeneous data formats of clinically used 12-lead ECG instrumentations, such as Standard Communications Protocol (SCP) ECG and Extensible Markup Language (XML) ECG. Additionally, there is no data link between clinically used 12-lead ECG instrumentations and mobile devices. To realize computerized 12-lead ECG examination procedures and ECG telemedicine, this study develops a DICOM-based 12-lead ECG information system capable of providing clinicians with medical images and waveform-based ECG diagnoses via Picture Archiving and Communication System (PACS). First, a waveform-based DICOM-ECG converter transforming clinically used SCP-ECG and XML-ECG to DICOM is applied to PACS for image- and waveform-based DICOM file manipulation. Second, a mobile Structured Query Language database communicating with PACS is installed in physicians’ mobile phones so that they can retrieve images and waveform-based ECG ubiquitously. Clinical evaluations of this system indicated the following. First, this developed PACS-dependent 12-lead ECG information system improves 12-lead ECG management and interoperability. Second, this system enables the remote physicians to perform ubiquitous 12-lead ECG and image diagnoses, which enhances the efficiency of emergency telemedicine. These findings prove the effectiveness and usefulness of the PACS-dependent 12-lead ECG information system, which can be easily adopted in telemedicine.
doi:10.1007/s10278-009-9231-7
PMCID: PMC3046657  PMID: 19711129
ECG; DICOM; PACS; telemedicine
3.  A client/server system for remote diagnosis of cardiac arrhythmias. 
Health care practitioners are often faced with the task of interpreting complex heart rhythms from electrocardiograms (ECGs) produced by 12-lead ECG machines, ambulatory (Holter) monitoring systems, and intensive-care unit monitors. Usually, the practitioner caring for the patient does not have specialized training in cardiology or in ECG interpretation; and commercial programs that interpret 12-lead ECGs have been well-documented in the medical literature to perform poorly at analyzing cardiac rhythm. We believe that a system capable of providing comprehensive ECG interpretation as well as access to online consultations will be beneficial to the health care system. We hypothesized that we could develop a client-server based telemedicine system capable of providing access to (1) an on-line knowledge-based system for remote diagnosis of cardiac arrhythmias and (2) an on-line cardiologist for real-time interactive consultation using readily available resources on the Internet. Furthermore, we hypothesized that Macintosh and Microsoft Windows-based personal computers running an X server could function as the delivery platform for the developed system. Although we were successful in developing such a system that will run efficiently on a UNIX-based work-station, current personal computer X server software are not capable of running the system efficiently.
PMCID: PMC2579164  PMID: 8563356
4.  Electrocardiograms of Adult Outpatients Followed-Up in Basic Health Care Units in the Community of the South Region of São Paulo City 
The Permanente Journal  2014;18(2):10-13.
Objective:
The electrocardiogram (ECG) is an important, available, and inexpensive diagnostic tool to assess cardiac symptoms. Few studies address the prevalence of ECG abnormalities or changes of a normal tracing in ECG in outpatients. Our objective was to evaluate ECGs of adult outpatients to determine whether changes from a normal tracing could disclose the patients’ cardiovascular health status.
Methods:
We evaluated all elective ECGs obtained in adult outpatients, from January 2009 to January 2010, at a municipal hospital in the city of São Paulo, Brazil. Electrocardiography was performed with a 3-channel, 12-lead machine (Dixtal Cardio-page EP-3, Dixtal Biomedica, São Paulo, Brazil), and results were interpreted by a cardiologist.
Results:
Electrocardiography was performed in 3567 adult outpatients, 62.5% of whom were women, with a mean age of 51 years (standard deviation [SD] = 16 years). Of the 1918 patients whose ECGs showed abnormalities (mean age = 56 years, SD = 15 years), 1137 were women. Electrocardiographic changes were found in 1184 of the patients. Minor changes were found in 38.3% of patients. A total of 3133 changes were found in 1918 abnormal ECG results. There was a statistical difference related to sex and age, and abnormal ECG results were more frequent in men. There was a high prevalence of abnormal ECG results in the population studied.
Conclusions:
There were more ECGs obtained from women; however, men and elderly patients more frequently had abnormal ECG results.
doi:10.7812/TPP/13-060
PMCID: PMC4022551  PMID: 24694315
5.  Demonstration of a Client/Server System for Remote Diagnosis of Cardiac Arrhythmias 
Health care practitioners are often faced with the task of interpreting complex heart rhythms from electrocardiograms (ECGs) produced by 12-lead ECG machines, ambulatory (Holter) monitoring systems, and intensive-care unit monitors. Usually, the practitioner caring for the patient does not have specialized training in cardiology or in ECG interpretation; and commercial programs that interpret 12-lead ECGs have been well-documented in the medical literature to perform poorly at analyzing cardiac rhythm. We believe that a system capable of providing comprehensive ECG interpretation as well as access to online consultations will be beneficial to the health care system. We present a client-server based telemedicine system capable of providing access to (1) an on-line knowledge-based system for remote diagnosis of cardiac arrhythmias and (2) an on-line cardiologist for real-time interactive consultation using readily available resources on the Internet.
PMCID: PMC2579882
telemedicine; knowledge-based systems; model-based diagnosis; cardiac arrhythmias; Internet
6.  Electrocardiogram and rhythm strip interpretation by final year medical students. 
The Ulster Medical Journal  2001;70(2):108-110.
The pre-registration house officers (PRHO) is often called upon to interpret electrocardiograms ECG. We invited final-year medical students who had successfully completed their written final examinations, to interpret three rhythm-strip tracings, and three 12-lead ECG tracings. The rhythm-strips were of ventricular fibrillation (VF), ventricular tachycardia (VT), and complete heart block. Of the three 12-lead ECG tracings, one was an inferior myocardial infarction (MI), one was atrial fibrillation (AF), and one showed no abnormality. Forty-six medical students attended. Of these, 50% had received no formal training in ECG interpretation, although 89% had tried to learn ECG interpretation from books. Only 9% felt confident in their interpretation of ECG tracings. Of the rhythm-strips, 100% correctly identified VF, 96% recognised VT, and 67% identified complete heart block. Of the 12-lead ECG tracings, 61 % recognised the MI, 54% recognised AF, and only 46% successfully identified the normal ECG as such. The group were significantly worse at 12-lead ECG interpretation compared to rhythm-strips (p<0.01). The members of the group who had received formal training in ECG interpretation were significantly better at interpreting both rhythm-strips and 12-lead ECG tracings (p<0.05). It would appear that formal ECG training as an undergraduate improves PRHO interpretation of ECG tracings, and the PRHO should not interpret 12-lead ECG tracings without consulting more senior medical staff.
PMCID: PMC2449230  PMID: 11795759
7.  Identifying QT prolongation from ECG impressions using a general-purpose Natural Language Processor 
Objective
Typically detected via electrocardiograms (ECGs), QT interval prolongation is a known risk factor for sudden cardiac death. Since medications can promote or exacerbate the condition, detection of QT interval prolongation is important for clinical decision support. We investigated the accuracy of natural language processing (NLP) for identifying QT prolongation from cardiologist-generated, free-text ECG impressions compared to corrected QT (QTc) thresholds reported by ECG machines.
Methods
After integrating negation detection to a locally-developed natural language processor, the KnowledgeMap concept identifier, we evaluated NLP-based detection of QT prolongation compared to the calculated QTc on a set of 44,318 ECGs obtained from hospitalized patients. We also created a string query using regular expressions to identify QT prolongation. We calculated sensitivity and specificity of the methods using manual physician review of the cardiologist-generated reports as the gold standard. To investigate causes of “false positive” calculated QTc, we manually reviewed randomly selected ECGs with a long calculated QTc but no mention of QT prolongation. Separately, we validated the performance of the negation detection algorithm on 5,000 manually-categorized ECG phrases for any medical concept (not limited to QT prolongation) prior to developing the NLP query for QT prolongation.
Results
The NLP query for QT prolongation correctly identified 2,364 of 2,373 ECGs with QT prolongation with a sensitivity of 0.996 and a positive predictive value of 1.000. There were no false positives. The regular expression query had a sensitivity of 0.999 and positive predictive value of 0.982. In contrast, the positive predictive value of common QTc thresholds derived from ECG machines was 0.07–0.25 with corresponding sensitivities of 0.994–0.046. The negation detection algorithm had a recall of 0.973 and precision of 0.982 for 10,490 concepts found within ECG impressions.
Conclusions
NLP and regular expression queries of cardiologists’ ECG interpretations can more effectively identify QT prolongation than the automated QTc intervals reported by ECG machines. Future clinical decision support could employ NLP queries to detect QTc prolongation and other reported ECG abnormalities.
doi:10.1016/j.ijmedinf.2008.09.001
PMCID: PMC2728459  PMID: 18938105
electrocardiogram; QT prolongation; Unified Medical Language System; natural language processing; concept identification; negation detection; decision support
8.  E-Learning as New Method of Medical Education 
Acta Informatica Medica  2008;16(2):102-117.
CONFLICT OF INTEREST: NONE DECLARED
Distance learning refers to use of technologies based on health care delivered on distance and covers areas such as electronic health, tele-health (e-health), telematics, telemedicine, tele-education, etc. For the need of e-health, telemedicine, tele-education and distance learning there are various technologies and communication systems from standard telephone lines to the system of transmission digitalized signals with modem, optical fiber, satellite links, wireless technologies, etc. Tele-education represents health education on distance, using Information Communication Technologies (ICT), as well as continuous education of a health system beneficiaries and use of electronic libraries, data bases or electronic data with data bases of knowledge. Distance learning (E-learning) as a part of tele-education has gained popularity in the past decade; however, its use is highly variable among medical schools and appears to be more common in basic medical science courses than in clinical education. Distance learning does not preclude traditional learning processes; frequently it is used in conjunction with in-person classroom or professional training procedures and practices. Tele-education has mostly been used in biomedical education as a blended learning method, which combines tele-education technology with traditional instructor-led training, where, for example, a lecture or demonstration is supplemented by an online tutorial. Distance learning is used for self-education, tests, services and for examinations in medicine i.e. in terms of self-education and individual examination services. The possibility of working in the exercise mode with image files and questions is an attractive way of self education. Automated tracking and reporting of learners’ activities lessen faculty administrative burden. Moreover, e-learning can be designed to include outcomes assessment to determine whether learning has occurred. This review article evaluates the current status and level of tele-education development in Bosnia and Herzegovina outlining its components, faculty development needs for implementation and the possibility of its integration as official learning standard in biomedical curricula in Bosnia and Herzegovina. Tele-education refers to the use of information and communication technologies (ICT) to enhance knowledge and performance. Tele-education in biomedical education is widely accepted in the medical education community where it is mostly integrated into biomedical curricula forming part of a blended learning strategy. There are many biomedical digital repositories of e-learning materials worldwide, some peer reviewed, where instructors or developers can submit materials for widespread use. First pilot project with the aim to introduce tele-education in biomedical curricula in Bosnia and Herzegovina was initiated by Department for Medical Informatics at Medical Faculty in Sarajevo in 2002 and has been developing since. Faculty member’s skills in creating tele-education differ from those needed for traditional teaching and faculty rewards must recognize this difference and reward the effort. Tele-education and use of computers will have an impact of future medical practice in a life long learning. Bologna process, which started last years in European countries, provide us to promote and introduce modern educational methods of education at biomedical faculties in Bosnia and Herzegovina. Cathedra of Medical informatics and Cathedra of Family medicine at Medical Faculty of University of Sarajevo started to use Web based education as common way of teaching of medical students. Satisfaction with this method of education within the students is good, but not yet suitable for most of medical disciplines at biomedical faculties in Bosnia and Herzegovina.
doi:10.5455/aim.2008.16.102-117
PMCID: PMC3789161  PMID: 24109154
Medical education; Distance learning; Bosnia and Herzegovina
9.  Physician Accuracy in Interpreting Potential ST‐Segment Elevation Myocardial Infarction Electrocardiograms 
Background
With adoption of telemedicine, physicians are increasingly asked to diagnose ST‐segment elevation myocardial infarctions (STEMIs) based on electrocardiograms (ECGs) with minimal associated clinical information. We sought to determine physicians' diagnostic agreement and accuracy when interpreting potential STEMI ECGs.
Methods and Results
A cross‐sectional survey was performed consisting of 36 deidentified ECGs that had previously resulted in putative STEMI diagnoses. Emergency physicians, cardiologists, and interventional cardiologists participated in the survey. For each ECG, physicians were asked, “based on the ECG above, is there a blocked coronary artery present causing a STEMI?” The reference standard for ascertaining the STEMI diagnosis was subsequent emergent coronary arteriography. Responses were analyzed with generalized estimating equations to account for nested and repeated measures. One hundred twenty‐four physicians interpreted a total of 4392 ECGs. Among all physicians, interreader agreement (kappa) for ECG interpretation was 0.33, reflecting poor agreement. The sensitivity to identify “true” STEMIs was 65% (95% CI: 63 to 67) and the specificity was 79% (95% CI: 77 to 81). There was a 6% increase in the odds of accurate ECG interpretation for every 5 years of experience since medical school graduation (OR 1.06, 95% CI: 1.02 to 1.10, P=0.01). After adjusting for experience, there was no significant difference in the odds of accurate interpretation by specialty—Emergency Medicine (reference), General Cardiology (AOR 0.97, 95% CI: 0.79 to 1.2, P=0.80), or Interventional Cardiology physicians (AOR 1.24, 95% CI: 0.93 to 1.7, P=0.15).
Conclusions
There is significant physician disagreement in interpreting ECGs with features concerning for STEMI. Such ECGs lack the necessary sensitivity and specificity to act as a suitable “stand‐alone” diagnostic test.
doi:10.1161/JAHA.113.000268
PMCID: PMC3835230  PMID: 24096575
electrocardiogram; myocardial infarction; quality; telemedicine
10.  A Research Method For Detecting Transient Myocardial Ischemia In Patients With Suspected Acute Coronary Syndrome Using Continuous ST-segment Analysis 
Each year, an estimated 785,000 Americans will have a new coronary attack, or acute coronary syndrome (ACS). The pathophysiology of ACS involves rupture of an atherosclerotic plaque; hence, treatment is aimed at plaque stabilization in order to prevent cellular death. However, there is considerable debate among clinicians, about which treatment pathway is best: early invasive using percutaneous coronary intervention (PCI/stent) when indicated or a conservative approach (i.e., medication only with PCI/stent if recurrent symptoms occur).
There are three types of ACS: ST elevation myocardial infarction (STEMI), non-ST elevation MI (NSTEMI), and unstable angina (UA). Among the three types, NSTEMI/UA is nearly four times as common as STEMI. Treatment decisions for NSTEMI/UA are based largely on symptoms and resting or exercise electrocardiograms (ECG). However, because of the dynamic and unpredictable nature of the atherosclerotic plaque, these methods often under detect myocardial ischemia because symptoms are unreliable, and/or continuous ECG monitoring was not utilized.
Continuous 12-lead ECG monitoring, which is both inexpensive and non-invasive, can identify transient episodes of myocardial ischemia, a precursor to MI, even when asymptomatic. However, continuous 12-lead ECG monitoring is not usual hospital practice; rather, only two leads are typically monitored. Information obtained with 12-lead ECG monitoring might provide useful information for deciding the best ACS treatment.
Purpose. Therefore, using 12-lead ECG monitoring, the COMPARE Study (electroCardiographic evaluatiOn of ischeMia comParing invAsive to phaRmacological trEatment) was designed to assess the frequency and clinical consequences of transient myocardial ischemia, in patients with NSTEMI/UA treated with either early invasive PCI/stent or those managed conservatively (medications or PCI/stent following recurrent symptoms). The purpose of this manuscript is to describe the methodology used in the COMPARE Study.
Method. Permission to proceed with this study was obtained from the Institutional Review Board of the hospital and the university. Research nurses identify hospitalized patients from the emergency department and telemetry unit with suspected ACS. Once consented, a 12-lead ECG Holter monitor is applied, and remains in place during the patient's entire hospital stay. Patients are also maintained on the routine bedside ECG monitoring system per hospital protocol. Off-line ECG analysis is done using sophisticated software and careful human oversight.
doi:10.3791/50124
PMCID: PMC3577868  PMID: 23299490
Medicine; Issue 70; Anatomy; Physiology; Cardiology; Myocardial Ischemia; Cardiovascular Diseases; Health Occupations; Health Care; transient myocardial ischemia; Acute Coronary Syndrome; electrocardiogram; ST-segment monitoring; Holter monitoring; research methodology
11.  Primary coronary angioplasty for ST-Elevation Myocardial Infarction in Qatar: First nationwide program 
Abstract: In this article, we outline the plans, protocols and strategies to set up the first nationwide primary Percutaneous Coronary Intervention (PCI) program for ST-elevation myocardial Infarction (STEMI) in Qatar, as well as the difficulties and the multi-disciplinary solutions that we adopted in preparation. We will also report some of the landmark literature that guided our plans. The guidelines underscore the need for adequate number of procedures to justify establishing a primary-PCI service and maintain competency. The number of both diagnostic and interventional procedures in our centre has increased substantially over the years. The number of diagnostic procedures has increased from 1470 in 2007, to 2200 in 2009 and is projected to exceed 3000 by the end of 2012. The total number of PCIs has also increased from 443 in 2007, to 646 in 2009 and 1176 in 2011 and is expected to exceed 1400 by the end of 2012. These figures qualify our centre to be classified as ‘high volume’, both for the institution and for the individual interventional operators. The initial number of expected primary PCI procedures will be in excess of 600 procedures per year. Guidelines also emphasize the door to balloon time (DBT), which should not exceed 90 minutes. This interval mainly represents in-hospital delay and reflects the efficiency of the hospital system in the rapid recognition and transfer of the STEMI patient to the catheterization laboratory for primary-PCI. Although DBT is clearly important and is in the forefront of planning for the wide primary PCI program, it is not the only important time interval. Myocardial necrosis begins before the patient arrives to the hospital and even before first medical contact, so time is of the essence. Therefore, our primary PCI program includes a nationwide awareness program for both the population and health care professionals to reduce the pre-hospital delay. We have also taken steps to improve the pre-hospital diagnosis of STEMI. In addition to equipping all ambulances to perform 12-lead electrocardiograms (ECGs) we will establish advanced wireless transmission of the ECG to our Heart Centre and to the smart phone of the consultant on-call for the primary-PCI service. This will ensure that the patient is transferred directly to the cath lab without unnecessary delay in the emergency rooms. A single phone-call system will allow the first medic making the diagnosis to activate the primary PCI team. The emergency medical system is acquiring capability to track the exact position of each ambulance using GPS technology to give an accurate estimate of the time needed to arrive to the patient and/or to the hospital. We also plan for medical helicopter evacuation from remote or inaccessible areas. A comprehensive research database is being established to enable specific pioneering research projects and clinical trials, either as a single centre or in collaboration with other regional or international centers. The primary-PCI program is a collaborative effort between the Heart Hospital, Hamada Medical Corporation and the Qatar Cardiovascular Research Centre, a member of Qatar Foundation. Qatar will be first country to have a unified nationwide primary-PCI program. This clinical and research program could be a model that may be adopted in other countries to improve outcomes of patients with STEMI.
doi:10.5339/gcsp.2012.23
PMCID: PMC3963721  PMID: 24688990
12.  Variation in the Use of 12‐Lead Electrocardiography for Patients With Chest Pain by Emergency Medical Services in North Carolina 
Background
Prehospital 12‐lead electrocardiography (ECG) is critical to timely STEMI care although its use remains inconsistent. Previous studies to identify reasons for failure to obtain a prehospital ECG have generally only focused on individual emergency medical service (EMS) systems in urban areas. Our study objective was to identify patient, geographic, and EMS agency‐related factors associated with failure to perform a prehospital ECG across a statewide geography.
Methods and Results
We analyzed data from the Prehospital Medical Information System (PreMIS) in North Carolina from January 2008 to November 2010 for patients >30 years of age who used EMS and had a prehospital chief complaint of chest pain. Among 3.1 million EMS encounters, 134 350 patients met study criteria. From 2008–2010, 82 311 (61%) persons with chest pain received a prehospital ECG; utilization increased from 55% in 2008 to 65% in 2010 (trend P<0.001). Utilization by health referral region ranged from 22.9% to 74.2% and was lowest in rural areas. Men were more likely than women to have an ECG performed (63.0% vs 61.3%, adjusted RR 1.02, 95% CI 1.01 to 1.04). The certification‐level of the EMS provider (paramedic vsbasic/intermediate) and system‐level ECG equipment availability were the strongest predictors of ECG utilization. Persons in an ambulance with a certified paramedic were significantly more likely to receive a prehospital ECG than nonparamedics (RR 2.15, 95% CI 1.55, 2.99).
Conclusions
Across a large geographic area prehospital ECG use increased significantly, although important quality improvement opportunities remain. Increasing ECG availability and improving EMS certification and training levels are needed to improve overall care and reduce rural‐urban treatment differences.
doi:10.1161/JAHA.113.000289
PMCID: PMC3828790  PMID: 23920232
emergency medical services; health policy and outcomes research
13.  Implementation of a portable device for real-time ECG signal analysis 
Background
Cardiac disease is one of the main causes of catastrophic mortality. Therefore, detecting the symptoms of cardiac disease as early as possible is important for increasing the patient’s survival. In this study, a compact and effective architecture for detecting atrial fibrillation (AFib) and myocardial ischemia is proposed. We developed a portable device using this architecture, which allows real-time electrocardiogram (ECG) signal acquisition and analysis for cardiac diseases.
Methods
A noisy ECG signal was preprocessed by an analog front-end consisting of analog filters and amplifiers before it was converted into digital data. The analog front-end was minimized to reduce the size of the device and power consumption by implementing some of its functions with digital filters realized in software. With the ECG data, we detected QRS complexes based on wavelet analysis and feature extraction for morphological shape and regularity using an ARM processor. A classifier for cardiac disease was constructed based on features extracted from a training dataset using support vector machines. The classifier then categorized the ECG data into normal beats, AFib, and myocardial ischemia.
Results
A portable ECG device was implemented, and successfully acquired and processed ECG signals. The performance of this device was also verified by comparing the processed ECG data with high-quality ECG data from a public cardiac database. Because of reduced computational complexity, the ARM processor was able to process up to a thousand samples per second, and this allowed real-time acquisition and diagnosis of heart disease. Experimental results for detection of heart disease showed that the device classified AFib and ischemia with a sensitivity of 95.1% and a specificity of 95.9%.
Conclusions
Current home care and telemedicine systems have a separate device and diagnostic service system, which results in additional time and cost. Our proposed portable ECG device provides captured ECG data and suspected waveform to identify sporadic and chronic events of heart diseases. This device has been built and evaluated for high quality of signals, low computational complexity, and accurate detection.
doi:10.1186/1475-925X-13-160
PMCID: PMC4273439  PMID: 25491135
Portable ECG device; Heart disease; Atrial fibrillation; Myocardial ischemia; Feature extraction; Embedded device
14.  Perspectives of patients and healthcare professionals on the impact of telemetrically supported patient self-management for chronic obstructive pulmonary disease (COPD): a qualitative study nested in the TELESCOT trial 
Background
Early identification of exacerbations reduces hospital admissions and may slow disease progression. The TELESCOT randomised control trial based in Lothian, Scotland, is investigating the impact of a tele-monitoring service for COPD with the primary aim of reducing hospitalisation.
Aim
The nested qualitative study explored the views of patients and professionals on models of telemetric service delivery and the impact on self-management.
Method
We undertook semi-structured interviews with patient and professional participants at different time points in the TELESCOT COPD trial. Transcribed, coded data were analysed thematically. Interpretation was supported by multidisciplinary discussion.
Results
38 patients (47% male, mean age 67.5 years) and 32 healthcare professionals provided 70 interviews. Both patients and professionals considered that home tele-monitoring had the potential to reduce the risk of hospital admission. Patients generally appreciated being ‘watched over’ by the tele-monitoring, which gave them confidence to manage their own condition. They used tele-data to improving their understanding of COPD, determine their current state of health and influence decisions about their daily activities. Numerical data (e.g. oxygen saturations) were particularly valued. Changes in readings validated their decisions to adjust treatment or seek timely professional advice, and eased access to clinical care. Patients valued the personalised care provided by tele-monitoring staff familiar with their circumstances and state of health. Professionals emphasised the potential role of telemetry in encouraging prompt compliance with medically defined behaviours and attitudes, though some doubted whether it would be sufficient to overcome a perceived reluctance on the part of patients to acknowledge and take ownership of the disease. There was also a concern that ‘fixation’ on monitoring physiological parameters (especially oxygen saturation levels), promoted a medical model of the disease and might increase dependence on services in some patients. The GPs and community nursing or physiotherapy teams who provided the supporting services emphasised the importance of ‘knowing the patient’ and ‘knowing what’s normal for the individual’ in using their clinical skills to interpret incoming tele-monitoring data.
Conclusion
Enthusiasm for tele-monitoring as a means of facilitating self-management and thereby reducing admissions is tempered by concerns about increased medicalisation and dependence on support services. Tele-monitoring provides data which can be used to support self-management decisions and acts as a channel for seeking professional support. The patient-practitioner relationship, personalisation and continuity of care were prioritised as important elements in delivering clinical support for tele-monitoring services by patients and professionals.
PMCID: PMC3571143
telehealth; COPD; self-management; primary care; continuity of care
15.  Screening Education And Recognition in Community pHarmacies of Atrial Fibrillation to prevent stroke in an ambulant population aged ≥65 years (SEARCH-AF stroke prevention study): a cross-sectional study protocol 
BMJ Open  2012;2(3):e001355.
Background
Atrial fibrillation (AF) is associated with a high risk of stroke and may often be asymptomatic. AF is commonly undiagnosed until patients present with sequelae, such as heart failure and stroke. Stroke secondary to AF is highly preventable with the use of appropriate thromboprophylaxis. Therefore, early identification and appropriate evidence-based management of AF could lead to subsequent stroke prevention. This study aims to determine the feasibility and impact of a community pharmacy-based screening programme focused on identifying undiagnosed AF in people aged 65 years and older.
Methods and analysis
This cross-sectional study of community-based screening to identify undiagnosed AF will evaluate the feasibility of screening for AF using a pulse palpation and handheld single-lead electrocardiograph (ECG) device. 10 community pharmacies will be recruited and trained to implement the screening protocol, targeting a total of 1000 participants. The primary outcome is the proportion of people newly identified with AF at the completion of the screening programme. Secondary outcomes include level of agreement between the pharmacist's and the cardiologist's interpretation of the single-lead ECG; level of agreement between irregular rhythm identified with pulse palpation and with the single-lead ECG. Process outcomes related to sustainability of the screening programme beyond the trial setting, pharmacist knowledge of AF and rate of uptake of referral to full ECG evaluation and cardiology review will also be collected.
Ethics and dissemination
Primary ethics approval was received on 26 March 2012 from Sydney Local Health District Human Research Ethics Committee—Concord Repatriation General Hospital zone. Results will be disseminated via forums including, but not limited to, peer-reviewed publication and presentation at national and international conferences.
Clinical trials registration number
ACTRN12612000406808.
Article summary
Article focus
Describes the protocol for a community-based screening programme to identify previously undetected AF in adults aged 65 years and older in the community, for stroke prevention.
Key messages
Early identification of AF would allow for timely referral for medical review and subsequent initiation of appropriate evidence-based thromboprophylaxis to prevent stroke.
The efficacy of screening for AF in a community setting is yet to be tested in a well-designed clinical trial.
Strengths and limitations of this study
The main strengths of this study are that it uses a simple community-focused strategy using innovative technology to screen for AF, which may be suitable for widespread implementation. The technology delivers a single-lead electrocardiograph available for immediate interpretation and corroboration by an expert cardiologist remotely.
The sample size of 1000 will inform the design and refinement of a future large-scale intervention and implementation study.
doi:10.1136/bmjopen-2012-001355
PMCID: PMC3383976  PMID: 22734120
16.  Transtelephonic Electrocardiographic Transmission in the Preparticipation Screening of Athletes 
Transtelephonic electrocardiographic transmission (TET) is the most widespread form of telecardiology since it enables clinicians to assess patients at a distance. The purpose of this study was to assess the efficacy and effectiveness of TET either by fixed telephone line (POTS) or by mobile phone in the preparticipation screening of young athletes. A total of 506 players, aged 20.5 ± 6.2 years, from 23 soccer clubs in the prefecture of Thessaloniki, Greece, were physically examined in their playfields by a general practitioner (GP) and had their ECG recorded. In 142 cases, and on the judgment of the GP, the ECG was transmitted via POTS and/or global system for mobile communications (GSM) to a specialised medical centre where it was evaluated by a cardiologist. The mean total time for recording, storing, and transmitting the ECG was four minutes per subject. It was found that the success rate for transmission at first attempt was similar for both fixed and mobile networks, that is, 93% and 91%, respectively. The failure rate in the GSM network was correlated to the reception level at the site of transmission. Only in about half (n = 74) of the transmitted ECGs did the cardiologist confirm “abnormal” findings, although in 16, they were considered to be clinically insignificant. Consequently, 58 athletes were referred for further medical examination. Our results indicate that TET (either by fixed telephone line or by mobile phone) can ensure valid, reliable, and objective measurements, and significantly contribute to the application of medical screening in a great number of athletes. Therefore, it is recommended as an alternative diagnostic tool for the preparticipation screening of athletes living in remote areas.
doi:10.1155/2008/217909
PMCID: PMC2275315  PMID: 18369413
17.  Microbial contamination of manually reprocessed, ready to use ECG lead wire in intensive care units 
Background: A number of studies have shown that non-critical medical devices can be contaminated with pathogens, including those resistant to antibiotics and thus become a potential vector for transmission. Electrocardiography (ECG) lead wire are non-critical medical device which are always attached on patient skin during their stay in intensive care unit (ICU). In view of the patient’s critical conditions and exposure to invasive procedures, identification and prevention of possible risks are important to prevent infection in ICUs.
Objective: The objective of this study was to determine the presence of bacterial and fungal contamination on cleaned and disinfected reusable ECG lead wires in intensive care units in a hospital.
Methods: A total of 408 cleaned ECG lead wires from 93 bed-side ECG devices and 43 ECG lead wires from 5 portable ECG devices from 4 intensive care units (ICUs) and 1 post-anaesthesia care unit (PACU) were sampled. ECG lead wires were stirred in 0.89% NaCl with added neutralizer for 30 seconds. Samples of the solutions were cultured directly on blood agar. The remaining solution was cultured on blood agar after sterile filtration. The number of colony forming units (CFUs) was counted and the microorganisms were identified.
Results: More than half of examined ECG lead wires (n=232; 51.4%) were contaminated with >30 CFUs/mL sample of bacteria or with risk pathogens. Gram-positive bacteria were the most frequently isolated organisms; particularly, coagulase negative staphylococci (96%) and aerobic spore forming bacteria (71.2%). Compared to ICUs, PACU had significantly lower proportion of contaminated ECG lead wires (p<0.05). The proportion of contaminated ECG lead wires, as well as mean number of cfus per ECG lead wire, was also significantly lower among multi-wire ECG leads compared to single-wire ECG leads.
Conclusions: Manually cleaned ECG lead wires may serve as a vector for transmission of nosocomial pathogens. The current reprocessing technique for ECG lead wires needs to be improved.
doi:10.3205/dgkh000207
PMCID: PMC3746603  PMID: 23967393
ECG lead wire; microbial contamination; ICU; PACU
18.  Assessment of the value of technician reporting of electrocardiographs in an accident and emergency department. 
OBJECTIVE: To assess the value of a cardiac technicians' report on electrocardiographs (ECGs) in reducing serious errors of interpretation by senior house officers. METHODS: A parallel study of interpretation of ECGs by senior house officers from 238 cases seen in an accident and emergency (A&E) department in a teaching hospital. 129 ECGs were reported by a cardiac technician at the time of recording and before the senior house officer wrote a report, and 109 were reported only by the senior house officers. Misinterpretations by doctors and technicians were graded by a consultant cardiologist on a four point scale and compared in the two groups. Serious errors (grade 4) were defined as those which potentially affected immediate management. RESULTS: The number of grade 4 errors of interpretation of ECGs by A&E senior house officers was reduced by 59% when there was a prior technical report (mean (SD), 18(17)% v 6 (7%); Fisher's exact test P < 0.05). CONCLUSIONS: When cardiac technicians provide a report on an ECG at the time of its recording, serious errors of interpretation by senior house officers are reduced.
Images
PMCID: PMC1343097  PMID: 9315933
19.  Electrocardiography Patterns and the Role of the Electrocardiography Score for Risk Stratification in Acute Pulmonary Embolism 
Korean Circulation Journal  2010;40(10):499-506.
Background and Objectives
Data on the usefulness of a combination of different electrocardiography (ECG) abnormalities in risk stratification of patients with acute pulmonary embolism (PE) are limited. We thus investigated 12-lead ECG patterns in acute PE to evaluate the role of the ECG score in risk stratification of patients with acute PE.
Subjects and Methods
One hundred twenty-five consecutive patients (63±14 years, 56 men) with acute PE who were admitted to Kyungpook National University Hospital between November 2001 and January 2008 were included. We analyzed ECG patterns and calculated the ECG score in all patients. We evaluated right ventricular systolic pressure (RVSP) (n=75) and RV hypokinesia (n=80) using echocardiography for risk stratification of acute PE patients.
Results
Among several ECG findings, sinus tachycardia and inverted T waves in V1-4 (39%) were observed most frequently. The mean ECG score and RVSP were 7.36±6.32 and 49±21 mmHg, respectively. The ECG score correlated with RVSP (r=0.277, p=0.016). The patients were divided into two groups {high ECG-score group (n=38): ECG score >12 and low ECG-score group (n=87): ECG score ≤12} based on the ECG score, with the maximum area under the curve. RV hypokinesia was observed more frequently in the high ECG-score group than in the low ECG-score group (p=0.006). Multivariate analysis revealed that a high ECG score was an independent predictor of high RVSP and RV hypokinesia.
Conclusion
Sinus tachycardia and inverted T waves in V1-4 were commonly observed in acute PE. Moreover, the ECG score is a useful tool in risk stratification of patients with acute PE.
doi:10.4070/kcj.2010.40.10.499
PMCID: PMC2978292  PMID: 21088753
Pulmonary embolism; Electrocardiography; Right ventricle; Systolic pressure
20.  A cost minimisation analysis of a telepaediatric otolaryngology service 
Background
Paediatric ENT services in regional areas can be provided through telemedicine (tele-ENT) using videoconferencing or with a conventional outpatient department ENT service (OPD-ENT) in which patients travel to see the specialist. The objective of this study was to identify the least-cost approach to providing ENT services for paediatric outpatients.
Methods
A cost-minimisation analysis was conducted comparing the annual costs of the two modes of service provided by the Royal Children's Hospital (RCH) in Brisbane. Activity records were reviewed to analyse volume of activity during a 12 month period in 2005, i.e. number of clinics, duration of clinics, number of consultations via telemedicine and in outpatient clinics, diagnoses, and travel related information. A sensitivity analysis was conducted using factors where there was some uncertainty or potential future variation.
Results
During the study period, 88 ENT consultations were conducted via videoconference for 70 patients at Bundaberg Base Hospital. 177 ENT consultations were conducted at the RCH for 117 patients who had travelled from the Bundaberg region to Brisbane. The variable cost of providing the tele-ENT service was A$108 per consultation, compared with A$155 per consultation for the conventional outpatient service. Telemedicine was cheaper when the workload exceeded 100 consultations per year. If all 265 consultations were conducted as tele-ENT consultations, the cost-savings would be $7,621.
Conclusion
The cost-minimisation analysis demonstrated that under the circumstances described in this paper, the tele-ENT service was a more economical method for the health department of providing specialist ENT services.
doi:10.1186/1472-6963-8-30
PMCID: PMC2270267  PMID: 18241356
21.  Development, Implementation, and Multicenter Clinical Validation of the TeleDICOM—Advanced, Interactive Teleconsultation System 
Journal of Digital Imaging  2010;24(3):541-551.
There is a need to make medical diagnosis available to critically ill patients on-site, without the necessity of time-consuming and risky transportation to larger reference hospitals. The teleconsultation of medical images is possible with the use of Internet-based TeleDICOM software developed in Krakow, Poland. Interactive consultation between two or more centers offers real-time voice communication, visualization of synchronized Digital Imaging and Communications in Medicine images, and use of interactive pointers and specific calculation tools. If direct interaction between physicians is not needed, the system can also be used in “offline” mode. In 2006, TeleDICOM was successfully deployed in the John Paul II Hospital in Krakow as well as a dozen other cooperating medical centers throughout southeast Poland. It is used for routine referral for cardiosurgical procedures. Aims of the study were to evaluate the image quality, software stability, constant availability, data transmission speed, and quality of real-time synchronized viewing of the images during the TeleDICOM teleconsultation; to evaluate the clinical utility of the TeleDICOM system; and to analyze the compatibility of TeleDICOM with the storage data formats of various imaging machine manufacturers. The analysis of angiographic offline teleconsultations was based on 918 patients referred remotely for coronary artery bypass grafting (CABG). The echocardiographic teleconsultations were performed during 63 live interactive consultations, several of them were presented to live during medical conferences. Measurement tools of the TeleDICOM software were tested against original measurement tools of echocardiographic machines from four different manufacturers. As a result of TeleDICOM consultation, a CABG decision was made in 806 of 918 patients consulted (87.8%). In remaining 12 patients, medical therapy or percutaneous angioplasty was recommended. CABG was performed in 98.6% of the admitted patients. Treatment decisions were changed after admission in 1.4% of patients—however, in all cases, it was not related to analysis of angiography data but rather to the change of clinical condition of the patients. All medical personnel involved in both offline and interactive teleconsultations judged the system positively in all assessed aspects. Lesser scores were observed only in the centers connected by slower networks. Measurements performed in the ECHO-TeleDICOM module were accurate as compared with those performed on a standard echo-machine (correlation r > 0.980, p < 0.001), independently of the echocardiograph model. Conclusion: This study demonstrates that telemedicine can improve patients' management using a clinically effective teleconsultation system. The TeleDICOM system is suited for professional use in the field of cardiovascular disease. It is also prepared for remote live demonstrations of clinical cases during large medical meetings.
doi:10.1007/s10278-010-9303-8
PMCID: PMC3092051  PMID: 20495992
Telemedicine; angiography; cardiac imaging; clinical application; computers in medicine; digital image management; image analysis; ultrasonography
22.  Telemedicine experience in the Brazilian Amazon 
Introduction
The development of telecommunication technologies and the diffusion of its eHealth applicability have enabled the implementation of a wide range of telemedicine systems, supporting clinical practices in different regions of the world. Distant and poorer areas of the globe, often characterized by difficult access and hazardous environments, are those that can most benefit from availability of remote consultations. This is due to the high costs associated with the transportation of specialized health teams and medical equipment between major cities and small villages, sometimes essential for the provision of adequate health care. Brazil is a country of continental dimensions with socioeconomic inequalities and uneven distribution of specialized health care, making it an ideal environment for establishment of eHealth initiatives.
Objective
The main objectives were (1) to develop an efficient method for acquiring and delivering patient medical information in remote areas using local Internet and (2) to assist urban and Indian populations in the Brazilian Amazon presenting with skin lesions and cardiovascular diseases.
Methodology
Ethical approval was granted by the research and Ethics Committees of PUCRS, Porto Alegre, Brazil. The project comprised: (1) triage and patient interview; (2) digital ECG and skin picture acquisition; (3) data management, storage and transmission; (4) delivery of expert second opinion based on development of a secure and confidential communication system between the receiving and delivering sites. Upon internet availability, the system was programmed to connect to the Microgravity Centre’s main server and to synchronise all collected data. Specialist health professionals accessed this server and the electronic patient records via a secure application installed on personal computers. Patient information, images, and exams were analysed by health specialists at the delivering site, and an opinion and treatment suggestion was offered. Cases that proved inconclusive were due to a lack of available information or the need for further laboratory exams. The opinions were secured in an encrypted PDF envelope and returned to the receiving site, where final diagnosis and treatment remained the responsibility of the local health team.
Results
Telecardiology (n=98): 59 (60.2%) normal ECGs, whilst 39 (39.8%) were altered, showing arrhythmias, conductive alterations and signs of ventricular hypertrophy. No patients presented signs of acute ischemia. In teledermatology (n=110): 57 (51.8%) patients did not present any skin disease. Among the patients with dermatological problems (n=53; 48.2%), the most common diagnoses were eczema, pityriasis versicolor, tinea, onychomycosis, and superficial mycosis. In five patients, the dermatologist suspected a cancerous lesion and recommended further investigation.
Conclusion
The telemedicine tools and the telecommunication system developed for this project proved to have a great applicability for diagnosis of dermatological skin conditions and for assessment of patient cardiovascular diseases. It was possible to remotely diagnose dermatological and cardiovascular conditions in a short period of time, at low cost and without the need for transportation of patients to other locations. It is believed that the eHealth assistance model applied in this project can be transferred to other places that have access to an Internet connection.
PMCID: PMC3571176
telecardiology; teledermatology; PUCRS; Brazilian Amazon; telemedicine experience
23.  Application of a low cost telemedicine link to the diagnosis of neonatal congenital heart defects by remote consultation 
Heart  1999;82(2):217-221.
OBJECTIVE—To determine whether accurate remote echocardiographic diagnosis of congenital heart disease could be achieved using a low cost telemedicine system.
DESIGN—Echocardiographic images obtained by a paediatrician from neonates suspected of having congenital heart disease were transmitted by a telemedicine link across two integrated service digital network (ISDN) lines to a regional paediatric cardiology unit for interpretation by a consultant paediatric cardiologist. The "tele-echo" diagnosis was verified by the paediatric cardiologist on direct consultation and echocardiography.
SETTING—Neonatal unit of Altnagelvin Hospital, Londonderry (a district general hospital) and the regional paediatric cardiology department, Royal Belfast Hospital for Sick Children.
MAIN OUTCOME MEASURES—Accuracy of the diagnosis made using the telemedicine link; impact on patient management.
RESULTS—Between September 1995 and September 1997 echocardiographic images were transmitted on 63 patients. A diagnosis was made in 61 (97%) (transmitted images were unsatisfactory in two). Congenital heart disease was diagnosed in 42 patients. Fourteen patients with major congenital heart disease were accurately diagnosed within 24 hours of admission using the telemedicine link and were transferred to the regional paediatric cardiology unit. A further 28 with less serious congenital heart disease continued to be managed at the district general hospital. Congenital heart disease was excluded in 19. Follow up consultation confirmed accurate diagnosis or exclusion of congenital heart disease in 57 (93%). There were four inaccurate diagnoses (6.3%; three undetected small ventricular septal defects and one pulmonary stenosis).
CONCLUSIONS—Transmitted images were of sufficient quality to allow confirmation or exclusion of major congenital heart disease. The telemedicine link facilitated early diagnosis and initiation of appropriate management in patients with complex congenital heart disease and avoided the need for transfer in those where significant congenital heart disease was excluded.


Keywords: congenital heart disease; telemedicine
PMCID: PMC1729129  PMID: 10409539
24.  Analysis of emergency department interpretation of electrocardiograms. 
The objective of the study was to determine the concordance of emergency physicians' and cardiologists' interpretations of emergency department (ED) electrocardiograms (ECG), to evaluate the impact of ECG misinterpretation on patient management, and to determine error rates as a function of the level of physician training and the specific ECG diagnoses. ECG interpretations were registered prospectively using a programmed-response data sheet. A second blinded interpretation by a staff cardiologist was assumed to be correct. Only ECG discrepancies with potential or probable clinical importance were considered as errors. The ED management of patients with ECG misinterpretations was reviewed by the investigators. The study was performed at an urban university hospital using 300 consecutive ED ECGs. The analysis found 154 errors of interpretation of which nine had probable clinical significance, and 56 had indeterminant significance. The concordance was weak at 0.69 (Kappa = 0.32, weighted Kappa = 0.30) with a significant discordance (McNemar Chi 2:P < 0.05). Error rates did not differ significantly between the diverse categories of physicians. In two cases, interpretation errors impacted patient management decisions but not patient outcomes. The most frequent errors involved repolarization abnormalities, ventricular hypertrophy and hemi-blocks. While discordance was significant, errors in ECG interpretation rarely impacted patient management. Prospective evaluation of ECG interpretation may be a useful means of gauging physician skills. It can also serve to focus educational activities on problem areas in electrocardiography.
PMCID: PMC1342419  PMID: 7804577
25.  Local innovation for improving primary care cardiology in resource-limited African settings: an insight on the Cardio Pad® project in Cameroon 
Cardiovascular disease (CVD) is an emerging threat to the health of populations in Africa. With the inadequate health infrastructures, understaffed and underfunded health systems, African countries are ill-prepared to cope with the increasing demand for care for CVD, particularly for populations in remote and underserved rural areas, where 60% of the population currently reside. Task shifting and telehealth have been suggested as strategies to overcome the current health workforce shortage in African countries, and to increase access to prevention and curative services for emerging CVD. However, strategies for promoting their incorporation into the existing health systems, have yet to be developed. The Cardio Pad® initiative (originating from Cameroon) seeks to provide appropriate solutions to improve the application of telemedicine for CVD prevention and control in remote African settings. The Cardio Pad® is a tele-cardiology device which provides a number of advantages in terms of cost, ease of use, autonomy and reduced technology requirements. It is a fully touch screen medical device which enables cardiac tests such as electrocardiograms (ECG) to be performed in remote underserved areas (rural areas for instance), while the test results are transferred wirelessly via mobile phone connection, to specialist physicians who can interpret them and provide assistance with case management. While most of the current telemedicine clinical services on the African continent receive most expertise from developed countries, the Cardio Pad®, a local invention by a 26-year-old Cameroon-trained engineer demonstrates how much innovative solutions to combat CVD and other health issues could and should be developed locally in Africa.
doi:10.3978/j.issn.2223-3652.2014.10.01
PMCID: PMC4221323  PMID: 25414826
Primary care; cardiology; telemedicine; Cardio Pad; Cameroon; Africa

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