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Why ECG telemedicine could be a worthwhile investment

The NHS could save £45m per year if ECG telemedicine is introduced widely in primary care, writes Joe Rafferty

The NHS could save £45m per year if ECG telemedicine is introduced widely in primary care, writes Joe Rafferty

Practice-based commissioning is intended to provide the best services for patients within general practice, thereby avoiding the inconvenience and delays of referrals to secondary care.

41198282Provision within surgeries enhances patients' experience and quality of care – the ultimate goal of the NHS. If this leads to financial savings to the NHS, so much the better.

One of the services that lends itself naturally to PBC is the use of telemedicine in the interpretation and evaluations of ECGs, avoiding referrals to outpatient clinics or even A&E.

Many surgeries do not have ECG machines and even those that do are not always confident in interpreting the results – GPs cannot be experts in everything.

In 2006, the Cumbria and South Lancashire Cardiac Network, together with NHS North West, undertook a pilot to see whether an ECG telemedicine system worked well and referrals to A&E could be reduced.

The service chosen was that provided by the independent sector company Broomwell Healthwatch, whereby ECGs taken at the surgery are transmitted down a telephone line to a 24/7 cardiac monitoring centre, which gives the surgery an immediate verbal evaluation, followed by a full report within minutes.

The service, in effect, imports ECG expertise into every surgery.

Pilot results suggest the initiative is welcomed by surgeries and patients, reduces unnecessary hospital admissions for cardiac conditions by 16%, and offers a significant financial saving – up to £45m a year for the NHS in England.

This is a true win-win for all and has led to NHS North West recommending to commissioners that they consider investing in the technology.

Pilot aims

Within primary care, ECGs are usually undertaken on conventional 12-lead ECG machines by nurses, who often have limited training in interpreting results.

GPs may also find it difficult to read ECGs, as many do not see them sufficiently often to interpret complex readings or, on occasion, maintain their clinical competence in this area of practice. Also, ECG machine readers may not always give accurate results.

The pilot aimed to investigate reliable and accurate options for interpreting ECGs. The technology should be simple to operate, reduce inappropriate hospital attendances and achieve financial savings that could be reinvested in patient care.

The technology

The Telemetric 12-lead ECG machines tested differ from conventional equipment in that they are handheld, and the ECG recording is transmitted wirelessly, within 45 seconds, as an acoustic signal along a land-based phone line to a call centre.

There it is captured and displayed on a screen and then interpreted by a team of clinically trained staff.

The equipment and service was provided by the Manchester-based firm Broomwell Healthwatch. Its interpreting team comprises practising nurses or medical staff with experience in coronary care or other secondary care units, who are subject to continuing training, testing and audit by consultant cardiologists.

The company was required to meet pilot criteria stipulating that patient safety and confidentiality would not be compromised and that the technology would be easy to use and would improve patient care.

Pilot method and results

Fifteen general practices (ranging from two to five GPs and 3,800-15,600 patients) and two established NHS walk-in centres were selected at random and were given a demonstration before agreeing to take part.

Every site was asked to use this equipment exclusively for six months, in the same manner as their usual equipment, so that no change in practice would take place to influence the results.

41198283Typically, a nurse at the GP surgery or walk-in centre would record an ECG on a patient and then telephone the call centre. They would receive an immediate verbal interpretation over the phone, followed by a full written report and copy of the ECG, sent by email or fax, for inclusion in the patient record. Whoever undertook the ECG was expected to complete a basic audit questionnaire.

Table 1 (left) demonstrates the three prime clinical indications of ECGs recorded. The figures are accounted for by the fact that walk-in centres provide only diagnostic services, whereas surgeries encompass the full range of diagnostic and treatment care.

The audit also showed:

176 ECGs were recorded, all by nurses, at the surgery or walk-in centre – none was taken on a home visit

165 (93.75%) of ECGs were undertaken easily

11 (6.25%) were identified as having technical problems, generally related to data transfer, a situation that has now been addressed; on no occasion was patient safety jeopardised

3 (1.7%) resulted in a poor trace because of problems with lead position and electrode contacts (this can also be encountered with conventional machines); adjustment and repeat ECG resolved the problem

50 (28.4%) resulted in a change in clinical outcome based on the ECG result

9 out of 55 (16.3%) of ECGs, according to results reviewed in more detail from one centre, resulted in avoidance of unnecessary use of hospital services and appropriate maintenance of patients in the community.

In relation to the last finding, some of the ECG results may not have been predicted from the patient's clinical presentation.

These included: two unknown heart rhythm disturbances (bradycardia and tachycardia); one significant change of myocardial infarction; three significant ECG changes requiring further assessment and five occurrences of pericarditis.

Some patients required a hospital admission, but for others medical assessment at the centre with amendment of treatment resolved the problem.

Those who went to hospital were sent with a copy of the ECG, providing hospital clinicians with a baseline from which to establish a treatment plan.

41198284Based on these outcomes at the one centre, calculations were made on potential financial savings (see table 2 left).

The figures may not be fully robust but represent as close an approximation as possible, using PbR tariff figures for 2007/8.

When extrapolated to the whole of England, the potential financial savings could be a minimum of £45m a year.

Staff feedback

As well as the pilot audit, Ipsos MORI was commissioned to undertake four focus groups of GPs, nurses and managers who used the service, plus a detailed telephone interview with Broomwell.

Practice staff said the equipment was very user-friendly, particularly its portability, which they said opened up the possibility of ECGs on home visits, but only if it became possible to transmit the recordings down a mobile phone line.

Staff added that patients were unanimously positive about, and trusted, the equipment. Undergoing an ECG in a familiar environment was an important benefit and less traumatic than going to hospital.

Practices in which ECG machines were not previously available were most enthusiastic about the technology.

Main staff concerns revolved around report delays and cost. Some staff reported waiting up to 40 minutes for reports, which had a knock-on effect on appointment times and made staff reluctant to use the equipment when traditional machines could give faster results.

Delays could have been caused by practice email systems rejecting or spamming emails sent by the company, poor network infrastructure in some areas of the SHA, and occasionally some surgeries having their fax machines turned off.

Staff differed over whether GPs or PCTs should fund the equipment. If PCT-funded, staff felt priority should be given to practices that did not currently have ECG machines or a GP confident enough to interpret results.

Broomwell Healthwatch felt strongly about the potential for huge NHS savings and said it could cope with increased demand for its service.

Practice staff suggested that the technology could be expanded to include spirometry and photographing skin lesions.

Taking it forward

NHS North West urged PCTs and practice-based commissioners to consider funding the technology, after considering:

• the availability of access to expert ECG interpretation

• confidence in the quality of the interpretation

• immediate support to aid clinical decision making

• the likely fall in inappropriate hospital referrals and/or admission for chest pain

• the ability to offer care closer to home

• the potential impact on delivery of the

18-week target through reduced outpatient referrals.

A further pilot was run in 2007 by the Cardiac Network of Greater Manchester and Cheshire (for more information, see www.gmccardiacnetwork.nhs.uk).

We know that 14 PCTs in our region are now using the service and a further 20 in other areas are in discussions about adopting the technology.

Joe Rafferty is director of commissioning and performance at NHS North West.

The full pilot report, Cardiac Telemedicine in Primary Care – Delivering Benefits for Patients and the NHS in Lancashire & Cumbria, is available at www.northwest.nhs.uk

ECG telemedicine could save the NHS £45m a year 60 second summary Clinical indications How a typical practice would save in the first year

The initiative can reduce unnecessary admissions by 16% and offers a significant financial saving.

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