Frequently Asked Questions

What is the 2005 Standard of Care for Interpreting ECGs?
The American Heart Association and the American College of Cardiology put forward a joint statement of their standard for 2005. Every ECG interpreted by a Cardiologist or an ECG-tested physician. The only board certification meeting this standard is Cardiology. All other physicians must be tested in reading ECGs using a recognized test to meet the standard.

This makes perfect sense in the light of the findings when physicians were solicited to take a test in ECG interpretation. Of the physician who felt they would pass such a test,
  • 70% of all non-Internal Medicine specialists failed,
  • 49% of all Internal Medicine specialists failed,
  • 9% of all Cardiologists failed!
On top of that bad news, up to 30% of all computerized interpretations fail.  Consider the fact that up to 11% of ECG interpretation errors are associated with morbidity and mortality. With an aging population that will require even more use of ECGs, this puts meeting the standard of care in a whole new light. 
What is a Qualified ECG Reader?
When D2D uses the term Qualified ECG Reader we are referring back to the 2005 Standard of Care for Interpreting ECGs.  We mean that the doctor is either a Cardiologist or a physician who has passed a recognized test like the WERT (See below).  However, in D2D's case, we have selected Cardiologists that have subspecialized in Electrocardiology.  These are the subspecialists that have ECGs at the core of their day-to-day work.  They are regarded as the experts in interpreting ECGs. 
Should you be happy with your current process?
When the AHA/ACC commission put forward their standard, they knew that many healthcare organizations weren't going to be able to meet that standard, especially not quickly, which is why the 2005 timeline was adopted. What D2D has found is that many institutions busy meeting challenges every day, have grown comfortable in not meeting the standard, so these institutions say "We are happy with what we are doing."

What the literature shows, is that physicians just can't judge if they are competent to read ECGs. (3)  On top of that, Physicians don't improve in reading ECGs over time without specific training and testing. So unless your ECG interpeters are Cardiologists or have passed a recognized test, you simply have no grounds on which to be happy with what you are currently doing. To put it even more succinctly, if your interpreters are not cardiologists, you have a better chance of getting a tail in a coin flip than getting a competent doctor interpreting your ECGs.

Please understand that the last sentence was not an overstatement, and we don't state it to sensationalize the problem.  We say it to bring the issue to sharp relief.  The best numbers in terms of patient care show that 100's of thousands of patient ECGs are misinterpreted every year in the United States, many leading to adverse outcomes.  Can anyone be happy with this state of affairs? 
How did ECG interpretation become a specialized skill?
ECGs have been around for over a hundred years, and so we must all be on guard against the "comtempt of the familiar".  Today's 12-lead ECGs may look mostly like they did years ago, but there is far more information available.  The 12-lead EKG is truly one fo the most powerful, non-invasive tests in modern medicine.  Using the right eyes on this low-cost test improves patient care at almost all of today's healthcare institutions.

While the training and board examinations required of cardiologists ensure expert ECG interpretation skills, the majority of ECGs are interpreted in primary care settings by non-cardiologists.  At one time, this was not understood as a problem.  However, as our understanding of the heart increases daily, so does the difficulty of accurately interpreting ECGs.  Today, more than 400 diagnostic statements can be made on the basis of a 12-lead ECG.  Developing and maintaining expertise in the nuances of ECG interpretation requires focused study and regular practice.  In 2001, the American College of Cardiology and the American Heart Association wrote in a joint statement that by 2005 a standardized examination should be the "primary path" to ECG interpretation privileges for all non-Cardiologists. (3)  Wagner ECG Reader Test (WERT) is a standardized exam that allows both Cardiologist and non-Cardiologist physicians the ability to demonstrate that their ECG interpretation skills are top quality.  Over 20 years ago, larger metro-based hospitals in North Carolina began to restrict interpretation privileges to Cardiologists or physicians that have passed WERT.

In the years since this Standard of Care was put forward, the specialty of Electrocardiology has flourished.  Now there are multiple tier-one journals and multiple national and international societies.  All of this has happened as the base technology has become more sophisticated and powerful.  The rapid evolution of this field lead Doctor 2 Doctor to decide that recruiting electrocardiologists was an important enough improvement in our diagnostics to be worth the extra work.

Is the malpractice risk for ECG interpretation worth worrying about?
Man hooked up to ECG machineAccording to the American Academy of Family Physicians, missed "myocardial infarction is the leading cause of litigation against family physicians.  More malpractice dollars are awarded for missed myocardial infarctions than for any other single diagnosis." (1)   Studies and court records show that failure to diagnose cardiac conditions is a problem in all primary care settings.  One study found "that 2% of ED patients with AMI were sent home mistakenly, most commonly related to problems in physician use of the ECG."  (6)  Expert ECG interpretation can significantly reduce the risk of these kinds of mistakes for many cardiac conditions. 

If my ECG machine provides computer interpretations, why do I need Doctor2Doctor over-reads?
Computer interpretations are inaccurate too often to be considered a substitute for physician over-reads.  A study published in the Journal of Medicine found that even physicians-in-training read ECGs 18 times more accurately than the best computer algorithms. (2)  Findings such as these led the American College of Cardiology (ACC) and the American Heart Association (AHA) to recommend that "all computer-interpreted ECGs be verified and appropriately corrected by an experienced electrocardiographer." (3) The ACC and AHA also emphasize that older computer algorithms do not compare previous ECGs.  Much like serial chest x-rays, review of a previous ECG can significantly enhance the accurate diagnosis of many conditions.  Doctor2Doctor's electrocardiologist use the previous ECGs supplied when making interpretations.   Another study (4) shows that error often results from physicians "believing" the computer ECG interpretation instead of their own, even when their interpretation is the correct one.  Again, the ACC and AHA warn quite emphatically that computer interpretations "cannot substitute for interpretations by an experienced electrocardiographer and should not be used in making clinical decisions." (3)
What is the Wagner ECG Reader Test (WERT)?
The Wagner ECG Reader Test is currently one answer to the following need expressed by the AHA and ACC in 2001 (3):
“Board certification in cardiology requires passing a separate portion of the board certification examination in cardiology that deals only with ECG interpretation. Thus, those individuals that are board certified in cardiology have demonstrated their competence in a standardized examination…  We recommend that by 2005 (standardized ECG examination) become the primary pathway, apart from cardiology board certification, to demonstrate competence when granting initial ECG over-reading privileges to physicians.”
Started 35 years ago, the Wagner ECG Reader Test was borne out of a need to train non-Cardiologists to read ECGs with equal proficiency as Cardiologists.  As Coronary Care Units (CCUs) were being established and cardiac care continued to advanced rapidly, the demand for expert ECG interpretation exceeded the supply of available Cardiologists.  Dr Galen Wagner, current editor of Marriott's Practical Electrocardiography, the classic textbook on ECGs, was asked to establish a standard by which non-Cardiologists could demonstrate an equivalent expertise in ECG interpretation.  The result is WERT. Thanks to the decreasing cost of ECG machines, the number of ECGs being produced today continues to outstrip the capacity of Cardiologists to over-read them. For this reason, Doctor2Doctor is committed to making over-reads by Certified ECG Readers as widely available as possible at cost-effective rates. For complete information about WERT, go here.
How do Doctor2Doctor ECG interpretations improve patient care?
As physicians, we must weigh many factors when developing a plan of care for a patient. Supporting data, such as labs, X-rays, and ECGs, each add to the clinical picture and planning for patient care.  Variability and uncertainty in any of these data can complicate and misdirect the overall plan of care.  Interpretations by certified physicians can help the clinician to optimize patient care by eliminating missed conditions and preventing overreaction to normal variants or other conditions that simulate more serious conditions.  In this scenario, everybody wins as the patient gets the best outcome and the clinician can focus on the best plan for the patient without unnecessary delays or “side excursions”.
How do Doctor2Doctor ECG interpretations lower my malpractice risk?
When our certified physician signs off on an interpretation report, they assume all legal liability for the correct interpretation of that ECG.  An unexpected benefit of this service is the idea of reducing the malpractice premium for physicians who exclusively use an expert to overread ECGs for their practice.  Doctor2Doctor is working with malpractice carriers to achieve such a reduced rate.  This idea has helped OB Physicians and Anesthesiologists to provide better care while at the same time saving malpractice dollars... a rare occurrence!  
Who are Doctor2Doctor's physicians?
Doctor2Doctor's physicians are practicing electrocardiolgists, licensed and in good standing in their state.  Doctor2Doctor's CMO does a limited number of ECG interpretations to monitor the system and physicians.  He has passed the WERT and is a contributing editor to the tier one journal, "The Journal of Electrocardiology."
I've read lots of ECGs.  Can I join Doctor2Doctor's team of certified physicians?
If you are an electrocardiologist, are board certified, and fully licensed to practice,  please contact us.  We are always looking to grow our team. We are not accepting physicians outside of electrocardiology at this time.  If you are currently reading ECGs at  your hospital, and you have not yet passed the Wagner ECG Reader Test, Doctor2Doctor would like to encourage and support you in either telling your organization about our service or taking the test.  Interpreting ECGs without being a cardiologist or being tested is no longer an operational alternative.  Please contact us for further information.  To begin the testing process on your own, contact Dr. Galen Wagner's office at (919) 668-8826.
How quickly does the interpretation report come back?
Doctor2Doctor guarantees that the originating organization will receive the completed interpretation report within 24 hours of the submission.  It is more often only a matter of a few hours.   It is important to note that a submission is not complete until either a previous ECG or the "No Prior ECG" form have been sent to Doctor2Doctor. We are exploring the concept of a "STAT" service for appropriate organizations.  If you would be interested in such a premium service that rapidly returns interpretation reports for emergent care conditions, please contact us.
What if my practice has a low volume of ECGs?
No problem.  There is no retainer or service fee.  You simply pay for what you use.  A key goal in establishing Doctor2Doctor is to bring the experts to any office so that patients everywhere will benefit.
What makes Doctor2Doctor interpretations so accurate?
First, Doctor2Doctor picks the best physicians from the subspecialty of Electrocardiology.  Second, we test our physicians before they come on board and as they work for us over time.  Third, we have access to high quality ECG-related continuing education which is built-in to our system.
What does Doctor2Doctor mean by "Net-Zero" on "Purchased Interpretations?"
D2D meets all the Medicare guidelines for a “purchased interpretation”.  This means your institutions will be in compliance when using Global CPT 93000 for billing purposes, instead of Technical CPT 93005 which you should be using currently. Since all ECGs would be interpreted by a D2D ECG Reader, and D2D operates as an a outside diagnostics lab, paying D2D is transparent to your institution's operating budget.  Paying D2D is simply tallying the 93000 codes billed and multiplying by your D2D contract rate for CPT 93010.  Since you are paying out only what you are taking in, you are net-zero. However, your staff time goes down because you don’t have to worry about the context of the ECG when billing.  To keep keep paperworkdown, Doctor2Doctor decided to bill at one flat rate.  Imagine, providing better patient care can actually reduce overall paperwork and time!
Do Doctor2Doctor interpretations replace the need for the attending physician to make an interpretation?
Doctor2Doctor's interpretations are guaranteed to arrive back at the physician's office within 24 hours of submittal, and often much sooner.  For routine use of the ECG, this allows full integration of the D2D Expert ECG Interpretation™ service with the patient care plan.  For more urgent interpretation, Doctor2Doctor is developing a suitable STAT service (please contact us for more information).  Until the STAT service is ready, the attending physician will need to make a preliminary interpretation until the formal interpretation is available.
Is Doctor2Doctor's service HIPAA compliant?
Yes, we take HIPAA compliance very seriously.  But, since reading about HIPAA is almost as fun as pouring lime juice on a paper cut, we'll save you from having to read about it here.  If you really want all the details, our customer service representatives will be happy to provide you with all the documentation and lime juice you desire.
Is Doctor2Doctor's service compliant with other countries confidentiality requirements?
Doctor2Doctor finds that the concerns for confidentiality for patient information is an important issue throughout much of the world. For the UK specifically, we can say we comply with the GMC 2004 Guidelines, "Confidentiality: Protecting and Providing Information". We are always ready to investigate new markets and believe our compliance with the US HIPAA regulations either meets or exceeds most countries' regulations. We will, however, work with you to verify this, to assure that we meet all your country's required standards.
Is it easy to start and stop Doctor2Doctor's service?
Acquiring Doctor2Doctor's service is simple from a business perspective.  We do not believe in tying anyone into services with minimum usage fees, contractual commitments or complex technical installation and training.  We have worked hard to make our service as simple to set up as possible.  And, our client contract makes it painless to exit the service in the unlikely event that one is dissatisfied: simply send a letter announcing the decision to discontinue the service (for any reason) and pay for the interpretations submitted before discontinuation.  
Sources:
  1. Davenport, John. "Documenting High-Risk Cases to Avoid Malpractice Liability." Family Practice Management. Vol 7 no. 9.
  2. Sekiguchi K, Kanda T, Osada M, et al. "Comparative Accuracy of Automated Computer Analysis Versus Physicans in Training in the Interpretation of Electrocardiograms."  Journal of Medicine. 1999; 30: 75-81.
  3. Kadish et al.  "ACC/AHA Clinical Competence Statement on Electrocardiography and Ambulatory Electrocardiography."  Journal of American College of Cardiology, 2001.
  4. Theodore L. Tsai, MD, Douglas B. Fridsma, MD, Guido Gatti, MA. "Computer Decision Support as a Source of Interpretation Error: The Case of Electrocardiograms." JAMIA, 2003.
  5. Hongo, Richard, MD and Nora Goldschlager, MD . “Overreliance on Computerized Algorithms to Interpret Electrocardiograms.”  American Journal of Medicine.  117 (2004) : 706-708
  6. Denise H. Daudelin, RN, MPH, Harry P. Selker, MD, MSPH. "Medical Error Prevention in ED Triage for ACS: Use of Cardiac Care Decision Support and Quality Improvement Feedback." Cardiology Clinics. Vol 23, 2005.