ECG Cloud is the award winning CLOUD based remote 12-lead resting ECG reporting SAAS (software as a service) application developed by Technomed Limited.

ECG Cloud is operated by Technomeds own inhouse telemedicine service, the Technomed Monitoring Centre. ECG Cloud is also available for licence to other third party cardiology service providers.

The Technomed Monitoring Centre, using ECG Cloud, offers GP practices, medical centres, and hospitals access to immediate, expert, clinician interpretation of ECGs at the point of care. This has the potential to save the NHS money by reducing the need for outpatient referrals. It also improves patient care by providing support for clinician patient management together with reduced waiting times for diagnostic tests.

By directly engaging specialist cardiology expertise at an early stage, a secondary care referral only occurs if the diagnostic result indicates that secondary care attention is immediately required or that all diagnostic or treatment options have been exhausted in primary care. This strategy has significant economical and patient healthcare benefits. As our team of experts operate remotely, we deliver a scalable and flexible service that easily accommodates the requirements of our customers 365 days of the year 24 hours a day.

ECG acquisition & interpretation issues

The ability to acquire a high quality electrocardiogram and subsequently accurately interpret it without specialist cardiology training is a recognised problem both inside and outside a hospital environment [1].

Many ECG machines are available with built-in computer generated ECG interpretation. Whilst these are sensitive, they lack specificity. The large number of false positive results that are produced, leads to unnecessary patient referral and anxiety. In addition, the absence of a relevant patient history reduces the likelihood of providing accurate patient specific advice [2].

Clinical studies suggest that non-cardiology clinicians have difficulty in interpreting all types of ECG when compared to cardiologists. The 2007 SAFE trial [3] concluded

Many primary care professionals cannot accurately detect atrial fibrillation on an electrocardiogram, and interpretative software is not sufficiently accurate to circumvent this problem, even when combined with interpretation by a general practitioner. Diagnosis of atrial fibrillation in the community needs to factor in the reading of electrocardiograms by appropriately trained people

The historically paper based process of printing and scanning followed by faxing or posting of ECG’s for expert interpretation is often extremely time-consuming, results in poor quality tracings and is generally inefficient. The ECG Cloud was developed to preserve the fidelity of the original recordings in digital format, speed up the reporting process and improve efficiency by integrating with existing systems to streamline referrals and subsequent patient management.

Although we recommend ECG Cloud is used with the Mortara range of ECG machines, ECG Cloud allows the option for digital upload of an ECG from any ECG machine brand.

What is ECG Cloud?

ECG Cloud is a browser based reporting and automated interpretation system. It allows test data and accompanying patient history to be acquired from multiple remote sites and analysed centrally by a competent ECG experts. An ECG machine can be placed in each clinical environment or can be deployed in a hub & spoke configuration. Both acquisition and technical reporting are carried out in a quality controlled environment. Interpretation and patient management best practice is provided in a reproducible manner by using a consultant cardiologist board adjusted algorithm. Acquisition, reporting and algorithm interpretation are subject to continuous audit. The audit output is used to further enhance and refine the system.

Why is ECG Cloud different?

Conventional primary care ECG service models use computer based methods for automated ECG measurement and pattern recognition followed by human interpretation of the results. The developers of ECG Cloud recognise that computer based methods for automated ECG measurement and pattern recognition are highly susceptible to signal artifact and that the common ECG environment is prone to sources of signal artifact. The developers believe that a well trained human brain is more effective at rejecting noise and artifact that arise in real life environments than a computer.

The ECG Cloud developers also recognise that presenting the same ECG to a number of ECG experts is likely to result in a variance in interpretation. In fact presenting the same ECG to the same expert on different days will sometimes result in a variance between interpretations. Algorithms are more reproducible in this respect.

ECG Cloud therefore turns the traditional model of ECG interpretation on its head by employing a human for pattern recognition and measurement using a standardised analysis protocol together with subsequent results processing by a computer algorithm to derive the optimum patient management recommendation.

Methodology

A detailed breakdown of the methodology, including visuals and a step by step process is available in the supporting videos.

The ECG Cloud System allows ECG’s to be recorded and immediately transmitted to a remote cardiology expert with the scope to return the results on a while-you-wait basis. The technology has proven easy to use in general practice and can be operated by healthcare assistants with the minimum of training. Using a Mortara ELI-10 with barcode data entry, an operator can process up to 20 patients per hour per workstation using a 6-lead ECG configuration (rhythm check) or 8 patients per hour with a standard 12-lead ECG configuration.

Practices subscribing to the service send ECG’s digitally to the Technomed Monitoring Centre and receive an immediate verbal interpretation, if required, followed by a full written clinician interpretation. The cardiology specialists at the reporting and analysis centre are fully qualified and are routinely audited. The telemedicine facility is operated on the NHS N3 network. The built-in quality control processes assure the highest standards of care and clinical governance.

Specific Issues addressed by ECG Cloud

Ease of use Ease of use is essential if one is to ensure high uptake of a new technology and change of habit. Referral into the Virtual Outpatient Department service can be easily initiated from a web interface or via an integrated application from the general practice electronic patient record system.
Care closer to home Remote diagnostics provides care closer to home for patients.
Education The ECG Cloud can educate GPs in the management of patients with abnormal ECG readings.
Expertise The service is clinician-led and therefore benefits from the expertise and knowledge of those who are qualified and trained to perform the activity.
Patient information The GP is able to explain to the patient the implications of the ECG report in the context of the primary care for that person. The patient is never confronted with raw test results without the ability to ask questions and have the data explained to him or her.
Poor ECG acquisition Factors that affect ECG acquisition quality are:

 

  • Good Skin Preparation
  • Use of quality electrodes
  • Good electrode positioning
  • Good electrode application
  • Artifact elimination

Virtual Outpatient Department deploys accredited ECG acquisition centers (Hubs). Only selected equipment and disposables are used within the Hubs and their operators follow strict procedural protocols. Staff are trained to acquire high quality ECG’s.ECG Cloud allows operator performance to be scored for each and every ECG. ECG acquisition problems are identified early and training offered when necessary. The ECG machine operator has the ability to reject the acquired ECG and repeat it prior to submission for reporting. Low fidelity recordingAll Hub ECG’s are recorded at a sampling rate of 1000 Hz and transmitted directly from ECG machine to the ECG Cloud central server in a raw data format without any signal degradation.Poor Data DisplayData is digitally converted and presented to the analysing expert as a viewable image without signal loss.Insufficient knowledge to report and interpret an ECGECG reporting is the process of the systematic analysis of ECG measurement and pattern recognition to produce a factual report. ECG Interpretation is the process putting the factual report into the context of the patient condition to arrive at a diagnosis and first-line patient management suggestion. Multiple clinical papers have demonstrated that both inside and outside hospital environments, clinicians who do not specialise in cardiology are less able to accurately interpret an ECG than their cardiology specialist counterparts. Measurement verification is only carried out by experienced cardiology specialists. ECG Cloud does not rely on accepting the machine derived measurement. The ECG CLOUD system ensures that all ECG measurements are verified and if necessary adjusted prior to diagnosis.Accurate Reproducible InterpretationStudies have shown that there is significant variability in interpretative output between cardiologists. The ECG Cloud suggest patient management pathway does not rely on the interpretation skills of one consultant but the the the consensus of opinion of a board of cardiologists.Lack of Clinical AuditThe quality of every ECG acquired is scored. A continuous sample of ECG’s are selected for audit. Both the quality of the ECG reporting and resultant ECG interpretation / management advice is examined. The audit results are used to to improve reporting quality and provide feedback for clinical management algorithm adjustment.Insufficient Patient HistoryAn ECG can only be accurately interpreted when place in the context of the relevant patient history. Lack of relevant patient history has been shown to significantly effect ECG interpretation quality. ECG CLOUD allows a quick and easy method to attach relevant patient history to accompany the ECG.Access to equipment/ utilisation of equipmentWidespread provision of ECG equipment within primary care brings the advantage of increased patient convenience but the disadvantages of poor equipment utilization and the challenge of training and maintenance of ECG acquisition skills. These are a particular issue in those practices with small list sizes. Using ECG CLOUD, the density of ECG Hubs within a given area can be adjusted to give a compromise between patient/clinician convenience and equipment utilisation. A clinician may refer a patient to his own service, if he resides within a Hub, or refer a patient to a neighbouring hub if the equipment and/or skills do not exist within his own practice (Spoke). This model has been proven to be more efficient in terms of capital equipment expenditure and less resource intensive with respect to maintaining skill competency.

Case Studies

Atrial Fibrillation Screening Using 6-lead Rhythm Check ECG Testing

Hub & Spoke Service Model Pilot Results

References

1] Hatala R, Norman GR, Brooks LR. Impact of a clinical scenario on accuracy of electrocardiogram interpretation. J Gen Intern Med. 1999 Feb;14(2):126-9.

2] Accuracy of diagnosing atrial fibrillation on electrocardiogram by primary care practitioners and interpretative diagnostic software: analysis of data from screening for atrial fibrillation in the elderly (SAFE) trial. BMJ 2007; 335 doi: http://dx.doi.org/10.1136/bmj.39227.551713.AE (Published 23 August 2007)

3] White T, Woodmansey P, Ferguson DG, Channer KS. Improving the interpretation of electrocardiographs in an accident and emergency department. Postgrad Med J 1995; 71: 132–13

4] Sur DK, Kaye L, Mikus M, Goad J, Morena A. Accuracy of electrocardiogram reading by family practice residents. Fam Med 2000; 32: 315–319.

5] Zwietering P, Knottnerus A, Gorgels T, Rinkens P. Occurrence of arrhythmias in general practice. Scand J Prim Health Care 1996; 14: 244–250.

6] Macallan DC, Bell JA, Braddick M, Endersby K, Rizzo-Naudi J.The electrocardiogram in general practice: it use and its interpretation. J R Soc Med 1990; 83: 559–562.

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