Managing Referrals in Vascular Medicine

Cardiovascular diseases (CVDs) are quite often characterised as insidious since they rarely present any symptoms until they are already in an advanced stage and difficult to treat and manage. The same could be said for cancer and many other medical conditions, but few present with such particularly acute, life-threatening complications. Myocardial infarction (MI) is a suitable example in more than one way.

It is well-known that MI can be asymptomatic (silent) in up to 68 % of cases and that females report non–chest pain symptoms more often than men (in whom chest pain is generally recognized as one of traditional symptoms of cardiac issues) [1, 2, 3]. There’s more: studies have shown that most female patients with MI have prodromal symptoms, which are often overlooked by physicians and are one of the reasons why females have higher rates of Sudden Cardiac Death (SCD) than men [4, 5]. Consequently, it could be said this is mirrored in (still) high cardiovascular mortality rates for women, even in economically developed countries like the United States, where cardiac disease was the cause of death for 299,578 women in 2017 (1 in every 5 female deaths) [6].

Women have it worse also in cases of misdiagnosis of acute MI: those with a final diagnosis of ST Segment Elevation Myocardial Infarction (STEMI) had 59 % greater chance of a misdiagnosis (at the first examination), those with a final diagnosis of Non-ST Segment Elevation Myocardial Infarction (NSTEMI) on the other hand had a 41 % greater chance than men [7].

But why are we even singling out MI and not virtually any other cardiovascular condition, which is also often asymptomatic, peripheral artery disease (PAD) being another good example, and associated with significant morbidity and mortality. The reason lies in the acute danger the condition poses to the patient and the risk factors that may not be evident at the time of diagnosis: they are not written in the patient’s medical record or are otherwise unknown to the emergency physician examining a patient with possible MI. Any mistake, even the slightest (misdiagnosis) on the part of the examining physician, who instead of immediately referring the patient to a cardiologist or a vascular surgeon, downgrades the patient’s urgency status, can have the gravest of consequences.

This notion is well supported by findings of a number of studies that analysed the rates of MI misdiagnosis, their causes and outcomes of associated malpractice claims. One detailed study of closed malpractice claims involving MI identified three main factors that contributed to successful lawsuits: misdiagnosis of MI in patients with typical chest pain and known coronary artery risk factors, a failure to perform careful evaluation in those with suspected CAD and a failure to perform indicated treatment (halting disease progression) [8]. Another study found that a missed diagnosis of MI can be as damaging (legally/financially) as a misdiagnosis, and singled out other reasons, including a lack of diagnostic test ordering, poor interpretation of diagnostic tests and (interestingly) the young age of patients [9]. The findings of an analysis of missed acute myocardial infarctions in various hospital emergency departments in Ontario, Canada were also telling, chiefly the fact that emergency departments with lower patient volume had 2-times greater odds of missed diagnosis of acute myocardial infarctions than higher-volume departments – one of proposed solutions (on the part of researchers) was the use of telemedicine to improve access to consultant expertise [10].

The red line that connects the aforementioned studies and becomes apparent, if one carefully reads through the lines, is the need for a centralised repository of all patient data, like a (paper) medical record, but one that can be easily and nearly instantly shared with selected medical professionals when and where it is most needed. This can almost invariably be achieved only through the use of modern, data management technologies, many of which have already revolutionised many areas of human endeavour and are poised to do the same for medicine, including cardiology.

Are Electronic Health Records (EHR) the right choice for cardiologists and vascular specialists?

Electronic Health Records (EHR), or Electronic Medical Records (EMR) as they are also called, are gradually replacing traditional medical records in a growing number of healthcare facilities since they offer several important benefits in comparison with their paper counterparts. First and foremost, the data is always in a uniform format, meaning there is virtually no risk of someone misinterpreting (the meaning) of data as can happen with the stereotypically (but unfortunately often evident) poor penmanship of many medical professionals that may lead to improper and harmful treatments [11, 12, 13].

The next is traceability, i.e. who, why and when new data was entered or existing data changed, which eliminates the chance of (un)intentional falsification of data and greatly decreases the likelihood of consequent malpractice claims (14). A study of the association between EHR use and the rates of paid malpractice claims in an office practice found that the physicians who used EMR had fewer malpractice claims: 6.1 % of EMR users had a history of paid malpractice in comparison to 10.8 % of non-users (a significant increase) [15].

Some EHR management systems also have the option of workflow automatization and the possibility of setting up (automatic, predefined) alerts: a study of the utility of EHR alerts for preventing drug nephrotoxicity identified an improvement in clinical outcomes in patients with Acute Kidney Injury (AKI) derived through the use of alerts [16]. Computerised alerts, in general, have also proven their worth in cardiology: in one study their usage was associated with a 19 % increase in the prophylactic use of anticoagulants and a 41 % decrease in the risk of deep vein thrombosis or pulmonary embolism in the 90-day period after discharge from hospital care [17].

Since many cardiologists are chronically overworked and may even suffer from burnout, such digital help (alerts) and well-designed EHR management systems could decrease their workload, improve diagnosis accuracy and ensure they are only referred patients that require their expertise [18]. An even better solution is a versatile, modularly designed diagnostic device with integrated support for EHRs, such as the MESI mTABLET.

The MESI mTABLET is a fully customisable, portable modern diagnostic suite, composed of a central unit (mTABLET), wirelessly connectable diagnostic modules (which are portable and battery powered themselves) and MESI mRECORDS software. The latter enables easy management and sharing of EHRs, diagnostic results and other patient data with interested parties (who need not be users of mTABLET or mRECORDS) and is supported by additional diagnostic apps available at the online mSTORE.

What is particularly suitable for cardiologists and vascular specialists is the combination of mTABLET and ECG, BP or ABI (the latter being a superior choice as it can measure BP in addition to ABI), TBI and SPO2 modules. All measurements taken with any of the diagnostic modules are wirelessly transferred to the mTABLET and automatically saved in the examined patient’s EHR. The cardiologist/vascular surgeon consequently has all the patient’s data in one location on the mTABLET in his hands and is better equipped to formulate a treatment plan for a specific patient or make accurate snap judgments in those with acute life-threatening cardiovascular conditions.

A well-designed EHR management system integrated in an ecosystem consisting of interconnected diagnostic devices with support for fast and seamless data sharing between interested parties is an invaluable tool in cardiac triage.

MESI mRECORDS: Highlights and future developments enhancing the entire diagnostic field.