Digital ECG Databases in the Regional Health Information Network of Crete

CE Chronaki^a, F Chiarugi^a, PJ Lees^a, E Charalambus^c, A Sykianakis^c,
G Vrouchos^c, N Antonakis^d, G Frantzeskakis^e, M Tsiknakis^a, SC Orphanoudakis^a,b

^aInstitute of Computer Science, Foundation for Research & Technology - Hellas, Heraklion, Crete, Greece
^bDepartment of Computer Science, University of Crete, Heraklion, Crete, Greece,
^cICU Department, Venizelion Hospital, Heraklion, Crete, Greece,
^dPrimary Health Care Centre of Spili, Crete, Greece,
^ePrimary Health Care Centre of Anogia, Crete, Greece

Correspondence: CE Chronaki, Institute of Computer Science, FORTH, PO 1385, 71110, Vassilika Vouton, Heraklion, Crete, Greece.
E-mail: chronaki@ics.forth.gr, phone +30 2810 391691, fax +30 2810 391601.

1.        Introduction

HYGEIAnet, the regional health telematics network of Crete, has for several years provided the infrastructure for a variety of medical informatics applications. Among these, are the primary health care information system, the cardiology information system, and the health emergency coordination centre information system all of which support the acquisition and archival of ECG records according to the SCP-ECG standard. Furthermore a web-based teleconsultation service that has been integrated with the primary health care information system supports the remote screening of patients with suspected heart problems. A key element in the consultation process is a digital electrocardiogram that is transmitted, along with relevant clinical data, from the PHCC to a shared episode folder accessible to cardiologists at the ICU of a regional hospital.

2.        Materials and Methods

The primary health care information system manages a comprehensive multimedia electronic health record that supports the main tasks of the PHCC: retrieval of a patient’s EHR, recording of encounter notes, order of laboratory & diagnostic examinations and receipt of results using the HL7 standard. The radiology department is equipped with a medical scanner and appropriate software for the storage of x-rays in the DICOM format. Most GP (General Practitioner) offices are equipped with a digital electrocardiograph and the GPs may record an ECG and archive it in the patient’s EHR.

Digital ECG databases have also been placed under pilot operation in the cardiology departments of district hospitals of the region. However, the hospital workflow is more demanding, involving cardiologists, technical and nursing stuff. The cardiology information system has been successfully integrated with an ECG management system, but full deployment in the hospital is still pending [1].

In a recent project, ambulances of the health emergency coordination centre have been equipped with a digital electrocardiograph that allows 12-lead real-time ECG and the recording and storage of ECG snapshots in the database of the emergency coordination centre.

Digital ECGs are also exploited in the context of an integrated teleconsultation service that manages shared episode folders [2]. Standard forms in Internet browser style are filled out with relevant clinical information, depending on the suspected cardiac problem and the current patient encounter, and are shared with the consultation centre. After reading the consultation form and viewing the ECG, the cardiologist may request additional information, including previous ECGs, x-rays, or laboratory data from the PHCC, and subsequently returns a diagnosis and instructions. After the teleconsultation, the episode folder including the shared clinical data, an outcome report and the activity log of the consultation is archived for future reference.

3.  Results

All PHCCs and many cardiology departments have the technical capacity to acquire and store digital ECGs. However, the penetration of digital electrocardiography in various HYGEIAnet sites varies dramatically. An encouraging observation is that number of ECGs archived as part of encounter records in some PHCC has increased from as low as 2% in 1999 to 60% in 2002.

The integrated teleconsultation service, which was validated during 2001 [2], has been gradually adopted as part of the daily practice in PHCCs. A comparative overview of current data against those of the pilot study shows that the most frequent reason for teleconsultation is still suspected ischemia, followed by arrhythmia, while there are a few cases of suspected acute myocardial infarction. While in some cases a confirmed diagnosis is provided based on the initial data submitted, in many cases there is need for further data such as old ECGs, laboratory data, x-rays or some clarification of the patient’s medical history. When hospital transfer is considered necessary, the cardiologists receive relevant clinical information prior to the patient's arrival and may provide instructions regarding patient management during transfer. So far, no patient suffered any negative effects as a result of the teleconsultation, but rather, they benefited through prompt evaluation and modification of drug therapy where necessary as well as avoidance of hospital visit in the majority of cases. In one case, where the patient went to the hospital anyway, the teleconsultation diagnosis was verified.

Our current work involves the assessment of teleconsultation services while the patient is under transfer to the hospital. Initial and follow-up ECGs, as well as vital signs and ECG monitoring snapshots, are available to the consulting cardiologist, who can provide instructions should complications occur, for example, during thrombolytic treatment.

4.        Discussion

In conclusion, our experience so far suggests that teleconsultation in cardiology, using digital ECG recordings transmitted through a regional network, can contribute significantly to the quality of care, especially in rural areas, promotes medical collaboration, and provides a clear benefit to patients, general practitioners, specialists and the regional health care administration.

The availability of previous ECG recordings in digital form in the PHCC’s database contributes to continuity of care and, according to our results, leads to a better diagnosis in several cases. As the archiving of digital electrocardiograms becomes part of the daily practice at all levels of healthcare delivery, the ECG repositories will grow in size and their utility is expected to better contribute to continuous medical education, health monitoring of the population and, above all, to the well-being of cardiac patients.

Acknowledgements

Work has been supported by the OpenECG thematic network under EC contract IST-2001-37711.

References

[1] F. Chiarugi, et al., “Support of Daily ECG Procedures in a Cardiology Department via the Integration of an Existing Clinical Database and a Commercial ECG Management System”, Annals of Noninvasive Electrocardiology, 2002 Jul;7(3):263-270.

[2] C.E. Chronaki, et al., “Preliminary Results From The Deployment Of Integrated Teleconsultation Services In Rural Crete”, Proceedings of the 28th Computers In Cardiology Congress, 23-26 September 2001, Rotterdam, The Netherlands.