i                  i.. .
                                                                                i                  i, .
                                                                                                     I @.
                                                                                                   1   i
                                                                                      @@fi
                                                                                !u5i!!       fililk@@ I#
                                                                                      *@@)o I @

                                COMPUTER ASSISTED EKG ANALYSIS
                                            AND THE
                                   REGIONAL MEDICAL PROGRAMS
                                   A Report of a Subcommittee
                                             of the
                    'NATION7AL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS
                                         August 3, 1971

                                                       ANALYSIS
                                 COIMPUTER ASSISTED EKG
                                 I.  Definition
                                 II. Description
                                III.  Potential Advantages and Critique
                                 IV.  Current RMPS Participation
                                  V.  Current Usuage and Potential
                                 VI.  Conclusions
                                                         Prepared by:
                                                         Kenneth S. Gimbel, M.D.
                                                         Herbert P. Dunning
                                                         John R. Farrell, M.D.

                                 COMPUTER ASSISTED EKG ANALYSIS
              1.  Definition:
                   Electrocardiographic interpretation utilizing a digital computer
              programmed to recognize specific characteristics of EKG wave contour
              and/or rhythmn.
             II.  Description:
                   The digital computer is capable of analyzing a large volume of
              electrocardiographic variables related to wave contour  magnitude,
              duration, direction, and frequency.  The recognition of deviations from
              programmed normal values in these parameters permits discrimination of
              abnormal electrocardiograms from normal ones.  Identification of patterns
              of deviation can then be translated into specific electrocardiographic
              diagnosis.
                   The computer, therefore, may serve to select out abnormal tracings
              form a large population of normals, with definitive interpretation being
              reserved for conventional methods.  Or, the computer may offer diagnostic
              interpretations with alternatives and exclusions.
                   Though individual systems differ with respect to specific hardware
              involved, they all share some common featur es:

                                              -2-
                  1.  An electrocardiographic preamplifier system designed to amplify
              the millivolt-range physiologic signals to a level which can be worked
              with conveniently.
                   2.  A means of converting this signal into a mode suitable for
              computer input (an analog-digital conver ter).
                   3.  A means of transmitting the converted signal to the computer,
              either-directly via telephone input, or by magnetic ta e recording:
                                                                    p
              on-line or delayed input.'
                   Major differences exist with respect to the number of variables
              analyzed.  Most systems utilize standard twelve lead electrocardiograms,
              while others use a special three lead (Frank orthogonal) approach.
              Still others record from a single lead and are principally concerned
              with continuous monitoring of rhythmn.
                   Most programs approach EKG analysis utilizing concepts of binary
              logic.  Multivariate statistical analysis has been used less frequently.
                   Systems also differ in their modes of data transmission, computer
              printout form, and storage and retrieval capabilities.
              Potential Advantap-es and Critique:
                   1.  Phy,,,sician Assistance - Automated electrocardiographic interpre-
              tation relieves the physician of a time-consuming task allowing him
              additional time  for more critical functions.  If computer-EKG programs

                                               -3-
               were fully automated at present, this assertion might be  valid.  In
               practice, however, most.programs are of a developmental nature and
               since the com uter interpretation is evaluated by a trained physician,
                          .p
               no time bbnefit is accrued. Automatic measurement of  intervals  and
               durations by the computer does save time for the physician.  Many  of
               these determinations, however, are carried out in some  institutions
             .by technicians, thus no advantage to the physician is realized.
                   The complexity of the computer program creates new personnel
               problems.  One obvious hindrance would be the increased demand for
               skilled computer programmers.  In addition, the time required for
               acquisition of the EKG on the computer unit exceeds that of the  con-
               ventional EKG.
                   2.      rac  - By adhering to programmed diagnostic criteria,
               observer variation is eliminated, uniformity of interpretation is
               enhanced, and accuracy is improved.  In addition,.expert EKG interpre-
               tation would be available to areas lacking skilled interpreters.  While
               observer variation is reduced in practice, the  computer  interpreted
               EKG has been found less accurate than EKGs read by conventional methods.
               Specifically, the incidence of false positive (abnormal) EI@Gs has varied
               from 2%-20%, and the incidence of false negative interpretations  has
               been reported from 3%-5%.      6, 7, 9)' The inability of the computer
               to accurately measure certain variables, e.g., the termination of the
               QRS complex; failure to detect waves of diminutive amplitude,  e.g.,

               small P waves; and artifacts created by poor  recording  and  transmitting
               techniques, all contribute to error.  Though  accuracy  has  improved
               during the past three years, considerable disagreement still is found
               between computer read and physician read  EKGs  (approximately  20%).
               Disagreement with respect to the nature.of the abnormality in an ab-
               normal EKG accounts for most of the difference, along  with  false  posi-
               tive interpretations. Separation of completely  normal  EKGs  from  those
               with borderline or gross abnormalities is achieved with a high      degree
               of accuracy.   (9)
                    3.  Volume Capacity    If current problems in diagnostic accuracy
               can be overcome, then automatic  (interpretation of) El@Gs will permit
               the increased utilization of this parameter as a diagnostic tool.  Since
               the actual computerized interpretive operation occupies  only  a  few
               minutes time, the major determinants of volume capacity  are  data  acqui-
               sition time, transmission time, and printout time.  Recording the
               standard twelve lead EKGs on a data acquisition unit takes'somewhat
               longer than with a conventional electrocardiograph.  This is offset,
               however, by computer data printout and EKG plotting,  freeing  the  tech-
               nician from the task of cutting and mounting the EKG.  Even  if  the  EKGs
               are reviewed subsequently by a physician-interpreter,  he  benefits  from
               premeasured intervals provided in the computer data printout.
                    Aside from the physician-sparing function,  therefore,  a  major
               potential benefit of the computerized EKG is its volume capacity.  In

                                               -5-
               order for this advantage to be realized, however, the computer system
               must be situated in the proper milieu, i.e., one providing an optimal
               volume of input.  This optimum will vary among computer systems depend-
               ing upon their degree of sophistication. It has been estimated  that
               the computer must perform 100,000 EKG readings yearly in  order  for
               maximal cost-effectiveness to be achieved.  (11)
                   4.  Cost Effectiveness - The cost of conventional EKGs is approxi-
               mately fifteen dollars per cardiogram. It has been estimated that  a
               computerized EKG should cost $2.50, thus representing a considerable
               savings.  (9)  This figure, however, will be arrived at only when@two
               conditions are fulfilled:
                        1.  optimal volume input is established;
                        2.  reliability and accuracy improve so that physician
               supervision is no longer required (in terms of comparative interpretation).
                   Current systems have not yet approached a level that will provide
               any economic advantage over conventional electrocardiographic interpre-
               tation. In addition to the present unfavorable operating costs,  the
               considerable expenditure for the computer and the recording and trans-
               mitting equipment must be recognized.
                   Assuming that the necessary degree of accuracy-is achievable..
               identification of a suitable (in terms of minimum input volume) environ-
               ment is necessary.  Since most hospitals require far less than 100,000

              EKGs yearly, in most instances independent hospital based computer EKG
              systems are impractical.  A single computer base subserving multiple.
              hospitals utilizing telephone linkages represents one approach.  Similar
              relationships between a computer base and multiple HMOs is also fore-
              seeable.  The potential of bringing the-expe@tise of the university
              hospital to outlying community hospitals and out-patient facilities is
              attractive from an RMPS viewp oint, both because it might improve the
              quality of medical care delivered in the smaller hospitals, and because
              it might promote interho@pital cooperation.  One must question, however,
              whether or not a need exists for other than conventional EKG interpre-
              tation in the community hospital; whether the computer would fulfill
              that need; or whether some other alternative would be more practical.

                                               -7 -
               IV.  Current Pu@ Participation
                   At present, five regions are involved with computer  assisted  EKG
               analysis: Missotiri,.The Intermountain Region, Florida, Rochester  and
               Memphis.  This section will describe the variations in computer EKG
               application as effected in the regions mentioned, and will indicate
               their success or failure in fulfilling PITS goals.
                        A.  Missouri
                        Computer-bioengineering projects accounted for a considerable
               part of the Regional Medical Program in Missouri during its initial
               three years of activity.  Project #19 entitled "Automated Electrocardio-
               gram for Rural Areas" attempted to develop a computer system for EKG
               interpretation serving remote areas. Fifteen remote  data  acquisition
               units linked by ordinary telephone to a dedicated computer in Columbia,
               Missouri, were established to evaluate the feasibility of such a system.
               The remote locations included several community hospitals, a private
               clinic, a prison, an individual GP practice, and a medical center.  This
               project was reviewed during a site visit in October of 1969,  attended
               by several leading experts in the area of the automated EKG.  It was
               noted that, (1) no need for the computer EKG service had been established
               and, (2) no cost savings had been demonstrated.  There were also several
               specific defects with reference to project design and management.' The
               National Advisory Council acknowledged that the endeavor had potential
               value.  Because, however, no clear advantage in terms of regionalization

                                                 -8-
               or health care delivery was foreseeable for the immediate future,
               Council advised reduction in funding wit h complete RMPS withdrawal
               by June 1971.  Continuation of the project utilizing s@pport from
               some other agency was recommended.
                    Many of the technical criticisms concerning this'@project  are  no
               longer applicable as improvements in program design and management have
               been instituted. Cost-efficiency  has  improved,  cardiologist  back-up
               interpretation has been provided, and reliability is improving.  In
               addition, a demand for this service of sufficient magnitude to make
               it economically feasible, has been identified.
                    The past four years experiences have (it appears)  resulted  in  a
               program of improved technical quality.  Economic justification demands
               that 50,000 yearly EKGs be analyzed in order to make the program finan-
               cially self-supporting.  At present, only 12,000 El@Gs are being recorded,
               far fewer than required.  However, a survey concluded in February 1971
               by Donald L. Wilson (Mo. RMP) seems to have established a need for this
               service.  Based upon an estimate of the average number of EKGs performed
               in the region, the expressed interest of various  physicians  and  hos-
               pitals, and the apparent lack of sufficient numbers of skilled inter-
               preters presently available, such a project may be justifiable.  On
               the basis of this survey and because of their past experience with the
               computer EKG, project #69 has been submitted     "Computer Processed
               Diagnostic Aids in a Rural Area."

                                                 -9-
                    The proposal aims at extending both the scope and magnitude of-
               the previous computer-EKG program by:
                         1.  Placing remote stations in suitable areas to generate
                              50,000 EKGs  early, enough to be cost effective.
                                          y
                         2.  Increasing the range of services provided:  pacemaker
                              follow-u,p, arrhythmia analysis, exercise-testing,
                              phonocardiography and spirography.
                         3.  Providing for planned decremental @ support, including
                              eventual financial independence by establishing a fee
                              for service system on a suitable unit volume.
               Two major problems remain:
                         1.   Computer accuracy, though improving, does not yet
                              appear to be at an acceptable levei.
                         2.  Even if the necessary volume-input is achieved, the
                              high cost of the analog data acquisition units, in
                              terms of purchase and maintenance, has to be reckonned
                              with.
               Admittedly, these are essentially technical problems that ar   e solvable;
               the question is when?

                                              -10-
                        B.  Florida
                        Project #3: Regional Computerized EKG Processing Center
                        This project was designed to provide inexpens ve, rapid and
              reliable EKG analysis to small hospitals in the North Central Florida
              area presently lacking this service. Objective data identifying a  need
              for this service in the area mentioned is not presented. An  initiation
              period of three years with yearly increments in the number of EKGs per-
              formed and the number of hospitals participating'was proposed.  Financial
              indepe ndence was to be achieved by charging a fee for service, $3.50 per
              EKG  (though $7.50 was indicated to be a more realistic figure).
                        A technical site visit conducted in January 1970 was generally
              favorable.  Continued funding was recommended for six months at which
              time the region would be required to provide:
                        1.  marketing strategy
                        2.  quality control plans
                        3.  cost analysis, utilization and evaluation study
                        4.  clinical EKG validation study
                        5.  choice of arrhythmia interpretation program
                        6.  a minimum of 100 EKGs daily.
                        During the 02 year, 31,000 EKGs were generated from ten
              participating hospitals.  Only one of thes6.institutions has agreed.
              to pay for the service, the agreed fee being $3.50 per EKG.  This figure
              had previously been admitted to be unrealistically low by the project's

              director.  A time schedule for initiation of fee for service EKG
              analysis in institutions presently receiving this service on a non-
              payment basis provides for $100,000 by the end of the grant period
              (03 year). Current interest levels of those nineteen  additional  hos-
              pitals representing potential purchasers in an area within a  hundred
              mile radius of Gainesville need to be identified.  Marketing  strategy
              appears to be incomplete. Procedures for clinical validation  of  the
              EKGS, and quality control have been started.
                        Project #12:  Computerized EKG Screening Program
                        A computerized EKG is one of multiple variables measured  in
              this cardiovascular disease screening program.  Patients with abnormal
              EKCs (or abnormalities in any of the parameters measured) are referred
              to a designated private physician. The computer  identifies  abnormal
              EKGs and provides a specific diagnosis.  The computer program being
              utilized is that described in Project #3.  Major expenditures are al ot-
              ted for purchase of data acquisition units ($42,750) and telephone service
              (49,000).  Estimated initial costs are $102,650, and yearly cost subse-
              quent to start-up is estimated at $76,000.
                        A technical site visit in January of 1970 observed that  the
              volume of EKGs screened was small, statistical'data was lacking,  and
              plans for patient follow-up were not clear. The projected  unit  cost
              per EKG of $3.00 appeared to be unrealistic.  Project i@12 has been com-
              bined with Project YPIO, -"Cardiovascular Screening Program in Four Rural
              Counties" to form Project l@10, "A Procram for Cardiovascular Screening
              and EKG Analysis."

                                              -12-
                        C.  Memphis
                        Project #8:  Regional Electrocardiographic Diagnostic Center
                        This project, now completing its third year,@was intended to:
                        1.  Improve the efficiency of service electrocardiography in
               the hospitals of the University complex by utilization of a central
               small computer linked to data acquisition units in member hospitals by
               telephone transmission.
                        2.  Provide this service on a regional basis.
                        3.  Improve the quality of EKG analysis in the region.
               Because of delays in equipment delivery and installation, the program
               has been operational for only one year. Notably lacking in the original
               ,grant application were:
                        1.  Documentation of a need for the intended services within
               the region.
                         2.  Detailed plans for marketing and expansion of the service.
                         3.  Demonstration of any potential cost-saving value.
               Apparently, the proposed expansion of routine computerized EKG analysis
               into the region met with resistance from the established medical com-
               munity.  Plans now center around development of an arrhythmia screening
               center serving local and regional coronary care units on a 24-hour

                                              -13-
               basis.  Two units are functioning, with plans to service an additional
               "ten or fifteen" units-in the region.  Notable by their absence are:
                         I.' Documentati on of a re ional need for this service and
                                                 9
               evidence of willingness to participate by the medical community at large.
                         2. Marketing  strategy.
                         3.  Details concerning the specific arrhythniia program to be
               utilized, and provisions for clinical validation and quality control.
                         4. Potential cost  saviIngs:  The original grant application
               hoped to achieve a fee for service compatible with the customary
               electrocardiographic charges in this community."
               A progress report containing the specifics of the past year of opera-
               tion with reference to the number of EKGs performed, clinical correla-
               tion, accuracy and reliability of the system, problems encountered and
               the proposed solutions, and objective evidence demonstrating improve-
               ment of EKG interpretation in the region would be most'helpful.
                         D.  Intermountai    ion
                         Project l@10:  Physiologic Data Monitoring System
                         Funded since 1967,'this project provides computer monitoring
               and analysis of multiple physiologic variables related to the cardio-
               vascular and respiratory  systems:

                          1.   Au tomated data analysis for four  cardiac  catheterization
                laboratories.
                          2. Automated spirometry (two hospitals).
                          3.  Automated EKG Analysis by Computer:  This service is
                utilized at two of,the five hospitals presently involved in the computer
                program.  To date, 14,170 EKGs have been analyzed by computer.
                          4.  On-line patient monitoring in a variety of intensive
                care unit situations.
                     A technical site visit in October 1969 commented upon  the  overall
                qualitative excellence of this project           demonstrated great
                sophistication and technical expertise in the development of computer
                techniques for automating physiologic measurements of cardiovascular
                function."  However, the member hospitals were noted to be highly
                sophisticated centers intimately concerned with cardiac catheterization
                and cardiac surgery.  With respect to electrocardiography, none of
                -these institutions lacked skilled cardiologists in EI<G interpretation.
                No plan  for applying the developing capabilities to other areas in
                the region, especially the less sophisticated small community hospita s,
                was proposed.
                     No change in this policy is in evidence in the 1970 progress report.
                Attention is predominantly directed towards five advanced hospitals in
                the Salt.Lake City Area. Specifically, demonstration of  a  need  for  a
                computer   EYG,pr 6gram in the remainder of the region and plans for
                extension of this activity into the region are lacking.

                                                -15 -
                         E. Rochester
                         Project #11:  Telephone EKG Consultation
                         The original grant application proposed the establishment
               of three networks consisting of five transmitting hospitals and one
               receiving center each, linked by telephone (dataphone) for  the  purpose
               of improved EKG analysis.  The system was to provide:
                         1.  A mechanism for transmission of EKGs on an emergency
               basis'for immediate interpretation by conventional means  thus  offering
               expert electrocardiographic services to outlying hospitals.
                         2. A framework for the establishment of a  computer  base  for
               the automated analysis of routine El@Gs transmitted from the participat-
               ing hospitals.
                         3.  An arrhythmia detection and monitoring service.
                         Estimated cost of equipping twenty transmitting stations
               and four receiving stations was @131,12,7, excluding salaries and  floor
               space rental ($105,600).  Council approved $30,051 yearly for two years
               for the establishment of the appropriate telephone network.  Funds were
               withheld from the computer aspect of the project until such time the
               region provided:
                         1.  Documentation of a clear need for the proposed service.

                         2.  Evidence that such a service would be accepted by the
               medical community in which it would be implemented.-
                         3.  Plans for development of clinical applicability, systems
               management, and marke ting.
                         The requested information was not included in the current
               grant continuation application, and plans for computer analysis seem
               to have been abandoned for the present.  A survey of the twenty-nine
               hospitals in the -ten counties comprising the region revealed that
               roughly 50,000 EKGs were done yearly in the region (figures fro m 1965).
               Thus even if all of the hospitals in the area were to participate in
               the proposed computer program, the total number of EKGs generated
               would barely meet the minimum level required to make the operation
               cost effective.

                                           COIQUTERIZED EKG IN REGIONAL MEDICAL PROGRAKMS
                                                                                                    Total  Direct  and
                               Project No.            Project Title              Project Years      Indirect Costs to Date
            Missouri              19 (49)       Automated Electrocardiogram            4                    $1,551,700
                                                for Rural Areas
            Intermountain         10            Physiologic Data Monitoring@           4                     1,365,400
                                                System
            Florida               03            Regional Computerized EKG              3                       274,400
                                                Processing Center
         ..Florida                12            Computerized EKG Screening             3                       105,200
                                                Program
            Rochester             11            Telephone EKG Consultation             2                        66,300
            Memphis               08            Regional El@G Diagnostic               3                       310,200
                                                Center

                                                -17 -
                   SUMMARY OF CURRENT RMPS ACTIVITIES WITH TliE CONPUTERIZED EKG
                    The projects discussed were analyzed on the basis@of written
               material submitted by the regions for the grant .reviei, process.  Addi-
               tional insight was gained from appropriate correspondence files and
               reports of past site visits.  Admittedly, the depth and effectiveness
               of a review limited to these sources is less than maximum.  Neverthe-
               less, some valid observations can be made.
                    1. Necessity - Lack of objective data demonstrating a  need  for  a
               computer-EKG system is common to all of the grant applications reviewed.
               A high level of intrinsic value is assumed to exist, and consumer  inter-
               est is taken for granted, with predictable results.
                    2. Acceptability - Failure to ascertain whether or  not  the  auto-
               mated EKG met with the approval of physicians practicing in the area
               of proposed implementation created difficulties in one region.  Certainly
               a minimal level of regional acceptance is mandatory in order  to  assure
               survival of the project.
                    3. Alternatives - In regions possessing a real  need  for  improved
               electrocardiographic services, a computerized service is (apparently)
               assumed to be the most effective mode available.  Little discussion
               of alternative approaches is evident, though such alternatives have
               proved to be of value in other regions.

                                                -18-
                   4.  Expense   All of the projects are outstanding with respect to
              the considerable expense encountered in purchase of appropriate data
              acquisition units, accessory electronic apparatus, and  telephone  rental
              costs.
                   5.  Cost-savings   None of the projects reviewed is able to provide
              reliable electrocardiographic interpretation at a cost  sufficiently  low
              so as to provide a clear economic advantage over conventional methods
              of interpretation.
                   6.  Reliability    The various contour and rhythmn programs used
              must be considered to be in a developmental sta-e.  All require subse-
              quent interpretation and confirmation by a skilled electrocardiographer.
              At the present time the computerized EKG is able to assist but  not  sup-
              plant the electrocardiographer.
                   7.  Volume-capacity   Although all of the grant applicants appreci-
              ate the capacity of the computer to analyze large numbers of El@Gs,  much
              less attention is directed towards the problem of assuring  the  computer
              a volume sufficient to make the operation cost-effective.
                   8.  Physician self-education - This particular potential benefit
              is referred to loosely by all of the projects. Little  or  no  documenta-
              tion of such an achievement is available.  Nor is objective evidence
              demonstrating any improvemnet in the quality of care delivered by phy-
              sicians utilizing this s.ervice apparent.

                                              -19-
                    9.  Regionalization  The establishment of te lephone linkages
              between one or more peripheral community hospitals and a Medical Center
              computer base is a rational way of promoting working relationships
              among the hospitals in a region.  Such cooperative arrangements are
              of enormous importance to the efficiency of the health care system
              of a region, and represent an important objective of the RMPS.  It is
              impossible to evaluate the quality of the interhospital relationships
              fostered by computer-EKG programs.  Accurate quantification of this
              function is not possible,on the basis of the written material available.
              Therefore comment on this important area must be reserved.
                   10.  Future Prospects - Realistic and detailed plans for phase-out
              of RMPS support through implementation of a sound fee-for-service
              schedule and marketing strategy are generally lacking.  Estimations of
              additional time required to reach such a stage ar e ambiguous.

                                                -20-
               V.  Current Usage and Potential
                    The electrocardiogram is a diagnostic tool essential for the
               recognition and evaluation of a variety of disturbances affecting the
               heart and cardiovascular system.  Application of computer techniques to
               electrocardiographic analysis may be considered on  sevieral levels:
                    L.  The Fully-Automated EKG - The definitive interpretation of
               electrocardiograms with respect to specific diagnosis and  alternatives
               without validation by conventional physician analysis.  Clearly, com-
               putei technology has not yet reached the stage of sophistication required
               to provide this service both reliably and economically.  The  automated
               EKG remains an objective. The amount of time required to  achieve  this
               goal is undetermined.  Though of potentially great value, projects
               directed towards this goal are investigative and developmental.
                    2. Prelimiftary Analysis - Premeasured and mounted EKGs with  sug-
               gested interpretations are of value because of the time-savings  earned
               with the computer print-out.  Diagnostic statements alert the physician
               reviewing the EKG to possibilities he may have overlooked, and serve as a
               Self-education device.  The value of such a service is a function of
               the skill and motivation of the utilizer.  The highly motivated and
               knowledgeable physician may derive much from the computerized EKG.
               The capacity and speed of the conventional electrocardiographer may  be
               enhanced when assisted by the computer.

                                                 -21-
                     To the average physician,seeking an.authoritative analysis, the
                computerized EKG offers less.  Ultimate interpretation resides with
                the physician-utilizer, and thus its quality varies with his  skill.
                Unless th e computerized EKG has been reviewed by a skilled  interpreter,
                its validity remains uncertain, and its value to the  physician  request-
                ing the service is diminished.
                    3.  Screening - At present, the computer is capable of separating
                normal EKGs from those with questionable and gross abnormalities, both
                efficiently and reliably.  Abnormal EKGs are then subject to conventional
                analysis for exclusion of false positives.  From an epidemiological
                standpoint, therefore, the computerized EKG is of great potential value.
                Epidemiologic surveys are outside the realm of RMPS (direct) concern.
                From the standpoint of disease detection for early diagnosis and manage-
                ment, several questions arise:
                         a.  Is the incidence of clinically important EI@G abnormali-
                ties great enough to justify the expense of a computerized detection
                program?
                         b. What is the incidence of  clinically  silent  abnormal  EKGS?
                Can symptomatic disease be detected more readily and  more  inexpensively
                through other means (e.g., questionnaires, blood pressure determina-
                tions, etc.)?
                         c.  Practically speaking, what is the importance of identi-
                fying those patients with abnormal EKGs and presumably  underlying  heart

                                               -22-
              disease?  Are we capable of altering the natural history of the disease?
              Can we offer any therapeutic intervention to Asymptomatic patients with
              clearly abnormal EKGS?  Thtse questions are of obvious,@importance.
              VI.  Conclusions
                   The fully automated EKG is still in a developmental stage.  Both
              technical and logistical problems have delayed realization of potential
              benefits attributed to a computerized system-.  Current systems rely
              upon subsequent validation of computer-interpreted EKGs by physician
              review.  Though he is capable of doing this more efficiently when
              assisted by a computer, his presence is essential.
                   No clear demonstration of improvement in the quality of medicine
              ,practiced is available within the four regions currently using such a
              system.  It, therefore, seems inappropriate for RMPS to support new
              project proposals designed along similar lines.  While the potential
              value of the computerized EKG remains attractive, its uncertain-future
              and considerable expense makes @IPS support impractical.  Nevertheless,
              development of an effective computer-El@G system is desirable.  Interested
              parties should be encouraged to seek financial Support from sources
              outside of RMFS.

                                          REFERENCES
              1.  Advantages of Three Lead Cardiographic Recordings:@ Pipberger,
                  Hubert V.  Ann. N.Y. Acad. Sciences  1 26:  @873-88 August 1965.
              2.  Computer Diagnosis of Electrocardiograms I Equipment.  Alexander,
                  David C. and Wortzman, Donald.  Computers and Biomedical Research.1;
                  348-365 Feb. 1968.
              3.  Computer Diagnosis of Electrocardiograms II.  Bonner, Raymond E.
                  and Schwetman, Herbert D.  Ibid. pp 366-386.
              4.  Computer Diagnosis of Electrocardiograms.  III  Bonner, Raymond E.
                  and Schwetman, Herbert D.  Ibid. pp 387-407.
              5.  Computer Diagnosis of Electrocardiograms.  IV.  Pordy, Leon et al.
                  Ibid.  pp. 408-433.
              6.  Computer Analysis of the Electrocardiogram:  A Joint Project.
                  Pordy, Leon et al.  J. Mt. Sinai Hosp. 1967, pp. 69-88.
              7.  Automation of Electrocardiographic Diagnostic Criteria.  Whitemand,
                  John R. et al.  JAMA  200:  pp. 124-130, June 12, 1967.
              8.  Evaluation of Routine ECG Screening of an Outpatient Population
                  With Computer Diagnoses.  Fieldman Arnold et at.  JAMA  205:
                  pp. 627-30, Aug. 26, 1968.
              9.  Computer Analysis of the Electrocardiogram:  Evaluation of Experience
                  in a Hospital Heart Station.  Gorman, @atrick A. and Evans, John M.
                  Amer. Heart J.  80:  515-21, Oct. 1970.
              10. Diagnostic Evaluation of ECG Data by a Computer.  Milliken, John A.
                  et at.  C.M.A.  J.  104:  801-5  May, 1971.
              ii. Computers in Cardiology.  Friedberg, Charles K.  Prog. Cardiovasc
                  Dis  13:86-96, July 1970.
              12. Computers, Electrocardiography and Public Health:  A Report o
                  Recent Studies.  Public Health Service Publication No. 1644, June 1967.