Specialist commentator comments
Comments on this technology were invited from clinical experts working in the field. The comments received are individual opinions and do not represent NICE's view.
All 4 experts were aware of, or had used, the remote electrocardiogram (ECG) interpretation services described in this briefing. Two experts believed that the services were not being widely used in the NHS, while the other 2 were unsure or did not comment.
Two experts believed that the services were novel, while another thought they were not. One expert believed the services were only a minor iteration of current care that had not been superseded.
One expert thought that some of these services were innovative because patient reports could be written and interpreted by experienced clinicians who had access to patient history. Two experts felt that non-commercial interpretation services available in their local hospital coronary care unit by trained clinicians offered competition to the services reported in this briefing because, in their opinion, they were either faster, free or better. One expert mentioned that some services developed in hospital had a system to immediately assess if ECG changes were new or pre-existing. They believed that this gave their service an advantage over the commercial services in this briefing. On the contrary, 1 expert had to stop using a commercial service because their local trust chose to provide their own in-house service instead. They felt that the commercial service was better than the service provided by the local trust because it had a faster turnaround time and less variability in reporting. One expert mentioned open access services for Holter monitors as a similar technology but added that they were often poorly supervised and did not take patient history into account.
All of the experts agreed that avoiding unnecessary hospital visits was a potential patient benefit. Three experts also agreed that high-risk cardiac symptoms could be identified earlier than with standard care and this would allow for earlier prevention or treatment to begin. However, 1 expert also expressed concern that such services may be used improperly in people with symptoms that need clinical review, such as acute chest pain or unexplained syncope. One expert mentioned that some of these services may provide the added reassurance to patients because the results would be reviewed by highly trained clinicians.
The experts stated various types of patients would particularly benefit from these services including: people with low-risk symptoms (history of vasovagal syncope, palpitations or hypertension); people with a pre-existing ECG abnormality because a comparison to a current ECG might prevent an unnecessary referral or because ECGs taken from Holter monitors are more likely to be misinterpreted in primary care; older people or those with mobility issues because there would be a reduced need for them to travel to hospital.
All of the experts agreed that a potential reduction in non-emergency referrals to secondary care specialist clinics would be a benefit to the health or care system. One expert said this reduction could lead to cost savings in regions where links to secondary care are poor. Another expert added that less money would need to be spent on secondary care and more could be allocated to primary care. Two experts thought that cardiac interpretation services could increase costs for their region but another expert thought that there could be cost savings if cardiologist resources were used more effectively by reducing unnecessary outpatient appointments. They added that this may also lead to better resource allocation in secondary care.
Three experts felt that little to no change to current infrastructure would be needed to use these technologies and that when needed they would presumably be provided by the companies. One expert believed that advanced ECG interpretation skills would be needed for clinicians to use any of the technologies.
Two experts expressed some concerns about the resource impact from adopting these technologies. One thought that the interpreter would need to take a holistic view and take clinical history into account for best management. They also felt that the most important element of such services was the skill set of the interpreter. The other expert reiterated that such services should not be used alone in managing high-risk symptoms and expressed worry that some practitioners could become overly reliant on these services. A third expert highlighted that primary care services would be expected to take responsibility for clinical decision-making if not referring patients onward for additional specialist follow‑up. No safety concerns or regulatory issues were raised surrounding the use of these technologies.
One expert mentioned that his knowledge of ECG analysis had improved after using an ECG interpretation service. Another expert felt that establishing local, non-commercial telemetry services should be attempted before using commercial providers. The expert acknowledged that some regions may not manage to establish close collaborations with their local hospital to successfully use non-commercial services. None of the experts had an opinion on how the services will adapt to the end of the N3 network but stressed the importance of continued data security. One expert expressed suspicion of services that provide diagnostic guidance without assessing clinical presentation.
Three of the experts felt that the technology would be an addition to standard care, rather than a replacement. One added that the services could be a replacement for outpatient referral where links to local cardiology services are poor. The fourth expert agreed, stating that the technology would replace the need to refer every patient for an initial outpatient appointment.
Two experts identified information technology-related difficulties, such as network and transmission problems, as the only practical issues with the services. One expert was not convinced by the published research because of industry involvement and limited real-world cost information. The expert felt that a pilot trial for an individual healthcare organisation would provide more useful data as results may vary across different locations. One expert thought that the services should agree to make audits of their performance available to purchasers. This would be particularly informative if the results included hospital referral rates and patient outcomes.