With healthcare increasingly under strain from an aging population, increased disease, and healthcare workers battling burnout, it's more important than ever to find ways of simplifying care delivery. Enhancing clinical connectivity can provide cardiologists with complete ECG data at their fingertips, whether they're at home, in the office, or seeing patients in the hospital.
But to get the most benefit out of digital management systems for ECGs, they'll have to be integrated into hospitals' electronic medical records (EMRs). This integration enables cardiologists to access patients' ECG history, along with the rest of their cardiology-specific or general medical data, to complete the clinical picture and improve decision-making.
ECG information must be digitized to ease this process, with devices connected to a central ECG management system to allow for the data to flow freely from collection, to a cardiologist who will interpret the results. The acquired ECG data are then transmitted and integrated into the hospitals' EMR, boosting the efficiency of cardiologists' practices, that could also improve patient outcomes.
The Benefits of EMR Integration
As a first step, moving to a digital system to manage ECG data allows for the application of algorithms to aid in the interpretation of the results. This is a particularly useful feature for physicians who don't routinely read ECGs.
The ECG management system can be integrated into hospital EMR systems, creating a one-stop shop for the secure storage of patient data (including near real-time test results) and easy communication. This adds up to speedier delivery of care to patients.
For example, if a patient is referred by their primary care physician to a cardiologist to follow up on an abnormal ECG, they might expect the cardiologist to already have access to that ECG when they arrive. In the absence of a digital ECG system integrated within an EMR, that might not be the case, and the cardiologist then has to spend time either tracking down the original ECG or performing another test. This could increase costs and cause delays in both the diagnosis and the initiation of appropriate treatment, and generate undue stress on the patient.
An abstract published in Circulation: Cardiovascular Quality and Outcomes illustrates how going digital with ECG data and integrating it into one hospital system's EMR brought the ECG acquisition-to-visualization time down dramatically, which can have a major impact for patients arriving at emergency departments with suspected cardiac disease. In the study, the average time at baseline when ECGs were viewable in the EMR after being formally interpreted by a cardiologist was 379 hours.1 It decreased to 235 hours during a transition period when a preliminary ECG could be uploaded immediately before formal interpretation. But implementing a standardized process encouraged a quick upload of the ECG (by setting a 30-minute goal for the acquisition-to-visualization time) and tracked individual and inpatient unit performance, arriving at a four-hour average for formal interpretation, with preliminary ECGs available much sooner.
Clinical Connectivity and Patient Outcomes
Use of integrated ECG systems can help mitigate human error, including delays in diagnosis and misdiagnosis stemming from a physician's inability to correctly interpret test results. ECG management systems are equipped with measurement and analysis tools to aid in interpretation and eliminate the need to wait for the ECGs to be faxed or sent in some other way, while also ensuring that all patient data remain secure.
This connectivity can be particularly beneficial for patients with acute chest pain, as it provides cardiologists with expedited access to transmitted prehospital ECGs and a repository for any subsequent tests. A study in Heart showed that among patients with STEMI or NSTEMI brought to the hospital via EMS, a prehospital ECG was associated with a greater likelihood of primary PCI within 90 minutes of the patient calling for help, and a lower rate of 30-day mortality.2
In a study in the Journal of Emergency Nursing, having a prehospital ECG in the system before patients got to the emergency room helped minimize errors introduced by EMS misinterpretation, which was one of the strongest predictors of undertriage of patients with chest pain when MI events were misclassified as low risk.3 The researchers advise reinterpreting the prehospital ECG if possible and repeating an ECG on arrival. Having the prehospital test results immediately uploaded to an ECG management system would allow for this process to happen faster, in turn leading to speedier treatment and an increased likelihood of meeting certain quality metrics, such as a door-to-balloon time under 90 minutes. A shorter time to reperfusion has been shown to improve outcomes in patients with acute MI.
As an added layer of protection against human error, artificial intelligence (AI) algorithms can be added to ECG management systems to help physicians reach the correct diagnosis in a timely fashion. In one study published in Circulation: Cardiovascular Quality and Outcomes, researchers conclude that "Our machine learning approach not only outperforms existing rule-based binary diagnostic criteria for ECG diagnosis against which it was compared, but also it more importantly expands the utility of the ECG as a clinical tool beyond present human capability."4
Another study in Nature Communications demonstrated that automatic interpretation of the 12-lead ECG using a deep neural network could outperform cardiology residents in recognizing six types of abnormalities, including first-degree AV block, right bundle branch block, left bundle branch block, sinus bradycardia, atrial fibrillation, and sinus tachycardia.5
In addition, ECG management systems, along with AI assistance, will likely prove useful in collecting and organizing the huge amount of data coming from consumer wearable devices equipped to measure ECG.
To learn more about the power of the ECG in today's clinical landscape, browse our Diagnostic ECG Clinical Insights Center.
Lessons from the COVID-19 Pandemic
The importance of embracing technologies that allow remote access to patients and their protected medical data quickly became apparent during the COVID-19 pandemic, as patients stayed home and hospitals and practices curtailed in-person visits. Cardiologists had to find ways to keep lines of communication open with their patients to help them manage their cardiovascular conditions and prevent outcomes from worsening. Enhanced access to patient data helped to address these challenges and laid the groundwork for continuing surveillance of patients with lingering cardiovascular effects after infection with the virus.
The stresses of the pandemic also pushed healthcare systems, and cardiology practices in particular, to become stronger and better prepared to weather future challenges. Governments and private organizations stepped up to provide funding needed to bolster a move toward telemedicine and other efforts designed to make systems more sustainable. Community clinics are taking on a greater share of care delivery to ease overburdened hospitals. And some healthcare organizations have moved to bring first-line diagnostic tests—like ECG—closer to patients through mobile and remote monitoring technologies, with the aim of improving patient outcomes.
Some Notes of Caution on Integrated ECG Data
Of course, cardiologists and other physicians need to be careful about relying on ECG management systems to ensure that all patient information is correct. They should also be aware of whether an uploaded ECG has been formally read and interpreted by a cardiologist, as algorithms used to interpret the ECG should always be overread by a physician to ensure accuracy.
Another concern around enhanced connectivity is cybersecurity. It is important to ensure that ECG data integrated into EMR-connected management systems remains secure and protected against unauthorized access. Indeed, dedicated ECG management systems are designed with security in mind, providing much more protection than faxing, for instance.
Despite these concerns, there are numerous ways that increasing clinical connectivity in a cardiologist's office can streamline workflows, make diagnoses quicker and more accurate, and put patients on the right course for good outcomes.
References:
1. Lambert CT, Sobol T, Kravitz K, et al. Abstract 257: Improving digital ECG acquisition-to-visualization time using EMR and institutional standard operating procedures. Circulation: Cardiovascular Quality and Outcomes. April 2018; 11: A257. https://www.ahajournals.org/doi/10.1161/circoutcomes.11.suppl_1.257
2. Quinn T, Johnsen S, Gale CP, et al. Effects of prehospital 12-lead ECG on processes of care and mortality in acute coronary syndrome: a linked cohort study from the Myocardial Ischaemia National Audit Project. Heart. May 2014; 100: 944-950. https://heart.bmj.com/content/100/12/944.info
3. Faramand Z, Frisch SO, DeSantis A, et al. Lack of significant coronary history and ECG misinterpretation are the strongest predictors of undertriage in prehospital chest pain. Journal of Emergency Nursing. December 2018; 45(2): 161-168. https://www.jenonline.org/article/S0099-1767(18)30485-9/fulltext
4. Tison GH, Zhang J, Delling FN, Deo RC. Automated and interpretable patient ECG profiles for disease detection, tracking, and discovery. Circulation: Cardiovascular Quality and Outcomes. September 2019; 12: e005289. https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.118.005289
5. Ribeiro AH, Ribeiro MH, Paixão GMM, et al. Automatic diagnosis of the 12-lead ECG using a deep neural network. Nature Communications. April 2020; 11: 1760. https://www.nature.com/articles/s41467-020-15432-4
