The technology

Advice

Innovations
Current NHS pathway or current care pathway
Population, setting and intended user
Costs
Resource consequences

The technology

An electrocardiogram (ECG) is a recording of the electrical activity of the heart and is used to diagnose cardiovascular disorders. Remote ECG interpretation consultancy services provide expert analysis of ECGs to support clinical decision-making. The services can receive and interpret ECGs – along with other information – using telephone and digital methods. This briefing describes 6 services that are available in the UK (see table 1).

There are 3 main types of ECG:

12-lead ECG: the standard diagnostic test used in primary care for a number of cardiovascular disorders. Ten electrodes are placed on the skin of the chest and limbs to measure the electrical activity of the heart from 12 angles. The signal is recorded for about 10 seconds.
Holter/ambulatory ECG: a monitor is worn for a period ranging from a day to a week, to record heart activity. The number of leads varies between manufacturers.
Loop/event monitoring: captures unusual heart activity over longer periods, in some cases up to 4 years.

An ECG of any type can be interpreted by a trained health professional or by dedicated software. The services in this briefing all offer interpretation by expert staff at remote locations. The ECG is transmitted from a primary care centre to the service provider. This can be done automatically from devices supplied by the services (see regulatory information). Alternatively, ECGs may be uploaded to the internet using a software platform or webpage, or sent by email.

A cardiac technician, cardiac nurse, consultant cardiologist or specialist consultant cardiologist such as an electrophysiologist interprets the ECG. Recordings from Holter, loop and event monitors can be interpreted live. The signal can be continuously transmitted to allow the interpreter to monitor activity in real time.

The interpreter returns a report with their ECG interpretation or recommendations to the patient's primary care clinician within an agreed timeframe. All 6 of the services in this briefing can receive ECGs recorded using any existing device. Three of the services are also able to supply third-party devices.

Five of the 6 services in this briefing are based in the UK. Smart Telecardiology is based in India and offers interpretation worldwide. The UK‑based services all support transmission using the N3 broadband network (with an NHS.net email address).

Table 1 summarises the remote ECG interpretation services included in this briefing. Other similar technologies may be available but are not included (for example, if they were not identified, or the company chose not to participate).

Table 1 Summary of included remote ECG Interpretation services

Company	Transmission	Interpretation	Proposed reporting time	Devices	Modality
MEOMED	NHS email, dedicated software upload.	Instant report* or consultant cardiologist's or electro-physiologist's written patient care plan with level of urgency. Offers live feedback between GP and consultant cardiologist after report is returned.	Under 24 hours; average 2 hours.	None.	12‑lead, Holter, loop/event.
Primary Diagnostics	NHS email, dedicated software upload.	Technician's written report – if a consultant cardiologist's expertise is needed, the ECG can be passed on to a service such as MEOMED.	Under 24 hours.	None.	12‑lead, Holter, loop/event.
Broomwell Healthwatch	Automatic by telephone, or digitally with NHS email.	Specialist nurse's or cardiologist's reports – quality control performed by consultant cardiologists.	Verbal report returned 'immediately' and a full written report within 15 to 20 minutes.	Supplies/leases third-party devices.	12‑lead, Holter, loop/event.
Express Diagnostics	NHS email.	SCST-accredited data analyst's report with pathway recommendation.**	Same day; up to 10 days.**	Supplies/leases third-party devices.	12‑lead, Holter.
ECG On-Demand	Automatic – digitally with NHS email or webpage upload.	SCST-accredited cardiac physiologist's written report with level of urgency. Quality control performed by consultant cardiac electro-physiologists.	Within 24 hours or 'immediately' on request. Average turnaround 2 hours.	Supplies/leases third-party devices.***	12‑lead, Holter/event.
Smart Telecardiology	Webpage upload or dedicated online platform.	Technician's or cardiologist's downloadable report.**	4 to 48 hours, depending on geographical location and depth of interpretation.	None.	12‑lead, Holter, loop/event.
Abbreviations: ECG, electrocardiogram; SCST, Society for Cardiological Science and Technology. * If ECG is normal and no patient information is provided. Depending on the customer's needs. * Loaded with (Glasgow) interpretation algorithms. The algorithms identify potentially abnormal ECGs, and the practice can decide to transmit only identified ECGs or transmit all ECGs.

Innovations

Remote ECG interpretation consultancy services may provide diagnostic reports quicker than with standard care. Interpretation takes between 15 minutes and 2 days and does not need a person to travel to hospital for an appointment. This may be particularly useful for specific populations, such as those who live in rural areas, people who work offshore and prisoners.

Interpreting ECGs often needs in-depth knowledge and continuous practice, so ECGs that are challenging to interpret are frequently referred to secondary care. Using remote ECG interpretation services may reduce the number of unnecessary referrals to secondary care and the number of misdiagnoses.

Current NHS pathway or current care pathway

A standard 12‑lead ECG should be offered to:

adults when atrial fibrillation is suspected (see NICE's guideline on atrial fibrillation)
people aged 16 and over if they have experienced a blackout (see NICE's guideline on transient loss of consciousness)
adults with recent onset chest pain, in certain instances (see NICE's guideline on chest pain of recent onset).

Other types of ECG may be taken in the above circumstances, if a 12‑lead ECG is inconclusive.

After taking an ECG, the practitioner can either: interpret the results and treat the person themselves; refer the person to an NHS consultant; or refer the person for emergency treatment. A referral to an NHS consultant cardiologist or electrophysiologist can take between 2 and 18 weeks and the patient must travel to hospital.

Automated ECG interpretation services are related technologies that use algorithms to interpret ECGs that are automatically uploaded to cloud networks or virtual private networks (VPNs).

Population, setting and intended user

GPs or nurses in primary care take ECGs from people with suspected cardiovascular disease. Remote ECG interpretation would replace a referral to an NHS consultant cardiologist or electrophysiologist in secondary care. A GP, nurse or healthcare assistant would record the ECG and then transmit the results to a remote location for interpretation. The consultancy service would then send a report back to the GP or nurse, with a recommendation for treatment.

Training may be needed for GPs to learn how to transmit the recorded ECGs and receive the reports.

Costs

Technology costs

Table 2 Cost of remote ECG interpretation consultancy services

Company	Cost (excluding VAT)	Additional information
Broomwell Healthwatch	12‑lead ECG service: £14 to £30 per report. Arrhythmia service – 24‑hour tape (Holter): £30 to £50 per report.	Price depends on speed of response and level of advice.
MEOMED	Cardiologist 12‑lead ECG service: between £22 and £30 per report. Arrhythmia service – (Holter): £65 per report.	Price varies depending on the usage for a practice per annum.
Primary Diagnostics	About £65 per analysis.	Price varies depending on the usage for a practice per annum.
ECG On-Demand	12-lead ECG service: £14 to £25 per report or a fixed monthly fee of £77 per 1,000-practice population, irrespective of the number of tests done. Holter analysis: 24 hours: £45 per report 48 hours: £70 per report 72 hours: £95 per report 7 days: £120 per report. Consultant cardiologist e‑consultation: £42 per report.	Holter analysis prices are based on the duration of the ECG is recording.
Smart Telecardiology	Fees for 12‑lead ECG interpretation start at £3 for a technician's report and £8 for a cardiologist's report.	Price depends on client location, reading cardiologists, turnaround time for reports and practice working hours.
Express Diagnostics	12‑lead ECG service: £10 to £25. Holter analysis: £25 to £195.	Price depends on turnaround time and recording time for Holter recordings.
Abbreviation: ECG, electrocardiogram.

Costs of standard care

The standard care in the NHS for ECG interpretation is referral to either emergency care or a cardiology outpatient unit. The unit cost per attendance for a hospital emergency department is £138 and for a cardiology outpatient appointment is £156 (Department of Health and Social Care 2016).

Resource consequences

It is estimated that 34.7 ECGs per 1,000 patients are recorded annually in GP practices (Wolff et al. 2012). Assuming that a GP practice sends all recorded ECGs to a service for interpretation, then the likely use is about 35 ECGs per 1,000 patients.

Table 3 NHS use of interpretation consultancies

Service	NHS use	Training
Broomwell Healthwatch	States that its services are currently used by around 70 CCGs in the UK.	Provided free of charge.
ECG On-Demand	States its service is used by CCGs, NHS trusts, GP alliances, and NHS healthcare providers such as mental health trusts and HMP.
MEOMED	Performed 3 pilot trials in Brent CCG, Liverpool CCG and Vale of York CCG.
Primary Diagnostics	Has provided its service to Suffolk CCG for the past 6 years.
Express Diagnostics	States that its services are currently used by 20 CCGs.
Smart Telecardiology	Not currently in use.
Abbreviations: CCG, clinical commissioning group; ECG, electrocardiogram; HMP, Her Majesty's Prison Service.

As long as the services are compliant with NHS communication networks such as the N3 network or health and social care network, no changes to current infrastructure are needed.

No published reports on the resource consequences of adopting the technology were found. Broomwell Healthwatch provided the results of 3 audits of pilot studies performed in Lancashire and Cumbria, Greater Manchester and Greater Birmingham. Cost savings were estimated based on secondary care referrals that were prevented in 61 to 65% of the cases. In Greater Birmingham, 1,934 audit forms were returned and the estimated cost savings were £97,672. In Greater Manchester, 2,377 secondary care referrals were prevented out of 3,732 ECGs, leading to estimated cost savings of £358,927. MEOMED also provided the results of a number of pilot studies (see table 5). It estimated that its service could save a 60‑practice CCG between £730,000 and £1.816 million per year.