By Dr. Payal Kohli, MD, FACC
Integrating ECGs and EMRs can help streamline the patient workflow, reduce costs, and improve patient quality of care. Perhaps the most effective way to illustrate the essential need for this simple healthcare technology is through a clinical example.
The challenge of unintegrated ECGs and EMRs in practice
My first consult of the day was a 58-year-old man with an abnormal ECG. The patient's PCP had obtained the ECG during an office visit for a routine physical and promptly referred the patient for a cardiology consultation. Aside from hypertension and mild sleep apnea, the patient—let's call him James—was otherwise healthy. Because of the COVID-19 pandemic, the visit was conducted virtually.
After completing the history and physical, I put James on hold and frantically tried to scan the EMR for the referral, hoping that the ECG had been sent with the referral for me to review. There was none. I turned to the PCP's note to see if it had at least an interpretation of the ECG so I could complete the consultation and advise the patient about the next steps. Again, nothing.
Frustrated, I went back to James and told him that I would have to track down the ECG and get back to him about the consultation management and plan. If I couldn't get it, I would have to repeat the ECG in my office. Essentially, the consultation could not be completed because any plan would have been highly dependent on the ECG. If he had bigeminy, I would have ordered ambulatory arrhythmia monitoring. If he had Q waves, I may have considered an echocardiogram or coronary artery disease testing. If he had left ventricular hypertrophy, it would have been an echocardiogram.
Even though I was on the same EMR as his PCP, the lack of integrated ECGs and EMRs had left me unable to complete my clinical workflow, provide an accurate diagnosis, offer a management plan, and complete the visit in a timely manner. The need for integrated ECGs and EMRs is greater than ever in situations like this.
The patient's perspective
The challenges and limitations of unintegrated ECGs and EMRs extend to the patient experience as well. Patients will likely be nervous and anxious to see a cardiologist, and in the case of James, he had been told by his PCP that he had an abnormal ECG. Anytime a patient hears that something could be wrong with their heart, they obviously worry about it.
Perhaps James spent many hours Googling potential diagnoses and his mind was racing with questions that he had hoped I would be able to answer. But then, after a sleepless night, when his consultation finally came, he was extremely disappointed. I didn't even have a copy of his ECG to review, much less the ability to offer him an explanation of why the ECG was abnormal and what needed to be done next.
In this day and age of online connectivity, these communication problems should not be occurring.
The benefits of integrated, automated ECGs and EMRs
These provider and patient perspectives illustrate that ECG integration into EMRs is a simple healthcare technology solution that offers significant advantages, such as:
- Streamlined clinical workflows: A digitized clinical workflow eliminates the need to manually fax paper documents (which, incidentally, are almost always poor quality for ECGs due to black and white replication of a color document). This can eliminate cumbersome, resource-intensive, and time-consuming processes.
- Improved patient care: The quality of patient care will likely improve if a provider can view a patient's serial ECGs through the EMR, even if the ECGs were obtained at multiple facilities or in another provider's office at the same facility. This would give the provider a full-picture view into the patient's prior records.
- Reduced cost: With less need for repeat ECGs, a hospital or practice could see significant cost savings.
- Fewer delays: Delays in EMR-based ECG visualization can substantially impact patient care for individuals with suspected cardiac disease, and integration of ECGs into EMRs could substantially reduce those delays.
One study in Circulation: Cardiovascular Quality and Outcomes investigated the impact of a standardized process for acquiring and uploading ECGs into the EMR using a metric called acquisition to visualization time (AtV) and compared the baseline method (where the ECG was uploaded after a formal read by a cardiologist) to the transition method (where the preliminary ECG was uploaded without the cardiologist's interpretation) to the full implementation method (where the ECG was uploaded within a 30-minute AtV goal timeframe).1 Unsurprisingly, there was a substantial 144-hour decrease in AtV in the transition group compared to the baseline group and a 375-hour decrease in AtV in the full implementation group.
ECG integration with EMRs can offer a convenient and efficient method for handling ECGs at the patient level and also for handling the thousands of ECGs that are processed through any given facility.
Considerations and cautions for fully integrated ECGs
Keep in mind that if an ECG has not yet been interpreted by a cardiologist and only has an automated interpretation, it should be taken within the appropriate context by the clinician ordering the ECG, as there might be errors in the automated algorithm that have not yet been overwritten by the cardiologist. Ensuring that patient identifiers such as name, DOB, and medical record number are correct is also critical when rapid integration is planned.
The clinical applications of ECG and EMR integration extend beyond the cardiologist's office. Whether for preoperative purposes, comparison with baseline ECG when a patient is presenting with chest pain symptoms, or QTc monitoring, the potential use cases for integrated ECG in EMRs are countless, and this technology solution will likely be viewed as essential to cardiology work in future years.
Dr. Payal Kohli, MD, FACC is a top graduate of MIT and Harvard Medical School (magna cum laude) and, as a practicing noninvasive cardiologist, is the managing partner of Cherry Creek Heart in Denver, Colorado.
The opinions, beliefs, and viewpoints expressed in this article are solely those of the author and do not necessarily reflect the opinions, beliefs, and viewpoints of GE Healthcare. The author is a paid consultant for GE Healthcare and was compensated for creation of this article.
Resources:
1. Lambert, Cameron T, Tim Sobol, Kathleen Kravitz, et al. "Improving Digital ECG Acquisition-to-Visualization Time Using EMR and Institutional Standard Operating Procedures." Circulation: Cardiovascular Quality and Outcomes 11, (2018). https://doi.org/10.1161/circoutcomes.11.suppl_1.257.
