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Chapter 11: THE RESTING ELECTROCARDIOGRAM COMPUTER APPLICATIONS

It has been almost 40 years since the first attempts were made to apply computer technology to the interpretation of ECGs.144 Today its use is universal.1,144-147 In general, computer systems for true analysis of ECGs have, as their main component, a program usually having the following four basic functions: (1) the measuring of ECG parameters, which includes an automatic wave-front-recognition section and a measurement section that extracts the wave fronts, a set of values, and control, (2) theinterpretation of previously acquired information, responsible for the final statements generated by the program, (3) the identification of various rhythms, both normal and abnormal, and (4) the comparison with previous ECGs to recognize significant changes. There is a lack of standardized, universally agreed-on diagnostic terms and criteria. This problem, however, is not solely that of computers but is related to all ECG interpretations, whether performed by individuals or by machines. It has to be remembered that the program used depends on criteria imposed on it by human programmers. Physicians should insist that the program selected has to be "tuned in" with the operational environment (e.g., community hospital or teaching institution, urban center or rural areas, etc.) in which it has to perform. Once a program has been selected and is in use, it requires initial and periodic evaluation. The most practical method consists of accepting as standard constrained human observers, the constrained observers being given a set of measurements or criteria agreed on before the evaluation. Proper computerization has the following definite advantages: (1) speed in providing reports with the resulting improved turnaround time, (2) optimal utilization of emergency ECG services, (3) reproducibility of measurements, (4) improvements in quality control, (5) possible decrease in physician's reading time and more consistency in interpretations, (6) enhancement of the capacity to handle large volumes of ECGs, and (7) substantial improvement in record storage and retrieval with better comparison with previous tracings.

Administrators are usually the ones selecting equipment, and frequently they know nothing about its medical performance. They usually use standard cost-effective, not medically-effective methods. That is, the economics involved-initial investment, operational costs, payroll, overhead, and professional fees-become priorities. This is important because it was estimated that even 10 years ago more than 40 percent of all ECGs recorded in the United States were obtained by some type of automatic system.144 Presently, however, this figure is reaching 100 percent. Finally, emphasis should be placed on the obvious: All computer ECG interpretations, particularly those of rhythm disturbances, must be checked by a physician qualified to interpret ECGs and with an in-depth knowledge of the program used. Decisions based on a computerized interpretation may, on occasion, lead to improper patient care. This also can have medicological implications. Of clinical importance was the report finding that computer interpretations of ECGs obtained 1 min apart were grossly different in 36 of 92 (39 percent) unselected pairs of tracings.148 The latter refers to only one program but nevertheless should be an impetus to designers and manufacturers to improve their product and a warning to those who rely, exclusively, on computer interpretations.148 The ACC/AHA Task Force on Guidelines for Electrocardiography states: "There is no computer program that can replace the skilled physician."4 Finally, cardiology fellows in training should interpret ECGs without a printed computer interpretation rather than by having to evaluate the latter.

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