D.C. cardiologist develops mobile app to speed diagnosis of heart attacks

January 16, 2012

In theory, the concept seems like a no-brainer for quickly determining if someone is having a heart attack: Use a smartphone, tablet or other device equipped with a camera to take video of the patient’s electrocardiogram, or ECG, which is typically used to diagnose heart attacks.

Then send that information in real time to doctors to make the diagnosis. With mobile networks, it takes two to three seconds. That’s much faster than the 10 minutes it normally takes for an emergency-room doctor to fax a printout to a cardiologist. And mobile is far superior to emergency medical services that still deliver ECG results to a hospital the old-fashioned way: by ambulance, along with the patient.

But in real life, cellphone coverage can be spotty. Recording live video from the back of a moving ambulance over bumpy roads is tricky. And institutions are often reluctant to overburden doctors or paramedics with yet another task, especially an unfamiliar one.

CodeHeart, a mobile application to speed diagnosis of heart attacks, has been under development in this area for two years, but it’s still struggling to enlist emergency medical crews’ participation for a pilot project. The slow going reflects the complicated nature of mobile solutions for the health-care-provider market, which has generally taken a cautious approach to new technology for storing and sharing patient information, experts say.

Providers are cautious

By contrast, mobile health technology has exploded in the consumer market, with 17 percent of cellphone owners, or 15 percent of adults, having used their cellphones to look up health or medical information, according to the Pew Internet and American Life Project. Consumers are increasingly using their phones to track, manage and improve health. For example, Text4baby is a free text messaging service that sends reminders to pregnant women and new mothers. The app is made available at no cost through a partnership of community health organizations, wireless carriers, businesses, health-care providers and government health agencies. In November, this service claimed to have reached nearly 250,000 people in the United States. [Also, see the Gazelle app in the story below.]

In prepared remarks last month to a convention on mobile medical devices, Health and Human Services Secretary Kathleen Sebelius noted that at Apple’s iTunes store alone, there are nearly 12,000 apps related to health, “a number that will probably have gone up by the time I finish speaking.”

But mobile health technology that aims to link providers to one another has developed more slowly for a variety of reasons, even though most doctors use smartphones, personal tablets and other devices within their own practices, analysts said.

There are compatibility issues. Each hospital has its own electronic information system. These systems are currently designed to work with a mouse, keyboard and monitor, and don’t adapt easily to touch-screen tablets, said John Moore, managing partner of Chilmark Research, which analyzes health-care information technology.

Among early-adopter hospitals, applications have focused more on easing access to hospital information systems than on tools for direct care, he said.

Some doctors and hospitals are also reluctant to adopt new technology in their offices. As Sebelius put it, “Health care has stubbornly held onto its cabinets and hanging files.”

And perhaps the biggest challenge is keeping personal health information secure.

“Hospitals and [chief information officers] are hesitant to adopt a new technology platform for fear of information leakage,” said Joe Smith, chief medical officer for the West Wireless Health Institute, a nonprofit medical research organization. At the same time, he added, technology is changing so quickly that hospitals are afraid “they’ll spend a couple thousand man-hours to bring one piece of technology online, only to find it lapped in a year.”

Multiple approaches

In cardiac care, many hospital systems have already invested heavily in commercially available systems that use dedicated hardware and software to perform one of the same functions as CodeHeart: Send ECG results from the field to the hospital via a secure digital file.

Montgomery County began using one in June. Doing so has resulted in faster diagnosis, officials said. That, in turn, has allowed some patients to bypass emergency rooms and go directly to a hospital’s cardiac catheterization lab for the artery-opening procedure known as angioplasty.

District ambulance crews and three D.C. hospitals plan to test the same commercial system, Lifenet, in a few weeks, said David Miramontes, medical director for the city’s emergency medical services department. The first year’s cost is about $100,000, funded by a grant from George Washington University Hospital, which received a donation from the nonprofit CTIA-The Wireless Foundation.

Unlike that system, the CodeHeart mobile application requires no dedicated software or hardware but does require a device with camera and Internet access. The app is portable and versatile, according to Lowell Satler, the Washington Hospital Center cardiologist who has been developing it with wireless carrier AT&T.

And unlike the commercial system, he said, the application has potential for use in emergency situations beyond cardiac care. The live video can let a neurologist evaluate a possible stroke patient or a dermatologist assess a mysterious skin rash remotely.

The application allows an authorized user to send a secure video and audio stream. The results are immediately accessible to consulting cardiologists on designated smartphones, tablets or desktop computers. Doctors can look at the patient and at the same time talk to an emergency room physician or first responder in an ambulance en route to a hospital.

Such a function can also be important when doctors at different hospitals want to confer quickly about a case and need access to patient information. Incompatible hospital information systems can be a barrier, and mobile apps could be one way to get around that problem, Satler said.

It’s unclear whether CodeHeart will eventually be made available commercially, but in any event, Satler said he will not seek to profit from it. His goal, he said, is widespread use of the application among physicians and emergency medical personnel.

Early obstacles

So far, only a handful of emergency workers in St. Mary’s County have tested the app from the field. When they were given cellphones two years ago, they had spotty coverage in remote areas. They also found that they had to stop the ambulance to take a clear video of an ECG to transmit, said Carol Sullivan, who heads the county’s Advanced Life Support Unit.

The emergency workers received more-modern phones recently but eventually returned those as well. “It just became a little bit cumbersome,” she said.

Satler is hoping that the District can try the app using tablets. Miramontes said the city is open to testing it in a few ambulances, but only after medics complete training for the commercial system.

“We’re so invested in this other system,” he said. “We may entertain [CodeHeart] because he has video, and for evaluation of stroke patients that would be awesome,” Miramontes said. “But we can’t saturate our providers with too much too quick.”

Satler is hoping to run his pilot for several more months. Six hospital emergency rooms are testing the application: Washington Hospital Center, Georgetown University Hospital, Montgomery General Hospital, St. Mary’s Hospital, Calvert Memorial Hospital and Fort Washington Medical Center.

Confirming the diagnosis

In one recent case, a 26-year-old woman walked into Georgetown’s emergency room with chest pain. A heart attack was unlikely, the doctor thought. Not only was the patient young; she was also fit and regularly ran marathons.

Her ECG results were not clear-cut, so the ER doctor eventually contacted Satler, who happened to be the on-call cardiologist for Washington Hospital Center. Using a portable webcam linked to her desktop computer, the Georgetown physician made a video of the ECG results by holding up the long sheet of paper and scrolling it from start to finish. She then used the CodeHeart app to transmit the video. Satler was having dinner with his father at a Rockville deli. But in three seconds, he received the results on his tablet. He viewed the pattern of spikes and wavy lines. Heart attack confirmed.

The patient was flown by helicopter to Washington Hospital Center and stabilized.

“We recognized it early, started treatment and aborted what could have been a terrible problem,” he said.

Doctors agree that mobile video feeds can be useful diagnostic tools. For the first time, the American College of Cardiology is showcasing cardio-related mobile applications, including CodeHeart, at its annual conference in March, said Marylou Forgione, associate director of business development for the group.

Emergency medicine doctors said they were interested in learning more about what the application could do and how it works.

“This could be the greatest thing since sliced bread. Or it could turn out to be another flash in the pan,” said Robert Bass, executive director of the Maryland Institute of Emergency Medical Services System, which licenses the state’s EMS providers.

Lena H. Sun is a national reporter for The Washington Post, focusing on health.
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