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The healthcare industry is stirring. In the words of Bob Dylan: “the times they are a changin’”.

It seems that with the advent of new technologies, coupled with a greater need to improve the current healthcare system, the digital health revolution arrived. This great experiment is about to start, but there seems to be a few problems in the way. There are some massive hurdles preventing the widespread adoption of digital health technologies in healthcare. Some examples include slow improvements in health IT, complicated healthcare and provider systems, segregated devices, and limited value proven by digital health companies. This has prevented novel technologies to enter and be tested in the greater healthcare system. This is very true when one looks at the electronic stethoscope, an example of a (possibly) revolutionary healthcare device.

The electronic stethoscope is not a new invention. It has been around for more than 20 years. And it changed nothing.

In that time computer and mobile processing power has skyrocketed, we have migrated to the cloud for storage and computing power and internet connectivity has become ubiquitous in developed nations. So why has the stethoscope been left behind? We were all expecting primary care doctors and nurses to be using electronic stethoscopes by now. Stethoscopes that are linked to the cloud, providing analysis and helpful insights into what the doctor or nurse were hearing. The interesting thing is that this problem is perpetuated by the stethoscope industry itselfironically.

Electronic vs Acoustic

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In the past few years the telemedicine market has grown substantially. A report estimated that the global telemedicine market would grow from $14B in 2014  to $35B in 2020. This growth has attracted many new players aiming to ‘disrupt the healthcare market’ including digital health companies, EHRs, technology integrators and providers, amongst others. These companies come in all shapes and sizes, and promise to deliver or enable high quality healthcare from a remote location. Telemedicine threatens to challenge current fee-for-service models by offering value-based care that can surpass many of the current challenges faced by those who work and offer health care.

Telemedicine, for me, solves two major problems. More than 46 million Americans live in rural areas. Telemedicine can help provide specialized services to these underserved communities, and could do this at a much more affordable rate. Another problem that can be solved is the large cost associated with having and retaining specialized services. Healthcare providers can centralize many services, and deliver care from a central point. This can increase the volume of patients served, and overcome many of the logistical challenges being faced by major healthcare organizations. This also means that professional healthcare services could be incorporated in businesses such as retail clinics, where basic primary care is served but not all healthcare services can be delivered. Telemedicine will expand the services they offer, and promise to do so at a reduced cost.

The question still remains – will Telemedicine disrupt healthcare in the way it imagines? Will it cause a new system to be adopted where all retail clinics, hospitals and caregivers access care via smartphones, tablets, or specifically tailored carts with a myriad of peripheral devices? I think this will depend on a few very important and key factors. Firstly, how well will this new technology be adopted? Healthcare technology adoption is famously slow. How will these companies expedite technological adoption in a market that clearly shows resistance to new tech? The second question to be asked is what kind of technology should be added, and what should this offering look like? Developers and integrators have to constantly iterate their technological offering to match customer preferences, and to ensure they add value. That leads to the third question – is there actual validated value that is being added to care being provided. Not perceived value that might encourage some sales, but actual validated value that will lead to the wide spread adoption of telemedicine?

So will telemedicine disrupt the healthcare market? Only time will tell, but the initial signs are promising. Telemedicine does look like the best solution to provide care to a large underserved part of the market.

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A long time ago in a galaxy far far away…oh wait, not so long ago, in our galaxy, technical support was a different ball game. If something that your company produced broke and the factory was in another country, you either made a plan to fix it locally, or order the part and wait out the months as it was being shipped to you. This is still the case in many industries, but in healthcare technology this has changed dramatically.

With the advent of information technology and smart support systems, the tech support landscape has changed. Now, with the click of a button, a support technician can help you establish what the problem is, talk you through a problem, and have you up and running within a few minutes. This is wonderful, but can sometimes also be a challenge. Support technicians might be in other countries, causing a delay in when you can appropriately schedule calls. This can be frustrating for multinational companies. But I believe some of these problems can be mitigated by providing excellent customer support.

The first thing a client support consultant must do is try keep your client happy. This is the most important thing to remember. If you behave like a idiot in front of your client and try to blame them for the mistake you most likely will lose your client and this will have a ripple effect across the whole company. To counter this you need to approach the problem from a different angle. You need to fit in with your client’s schedule, this can be difficult but an arrangement can always be made so that both parties are happy about the arranged time.

You must always keep an open line of communication. Talk to your client and try to understand the frustration that they are experiencing. Most of the time the problem is easily solved and can be fixed within 10 minutes. If it takes longer remember the second rule: keep your client informed. An informed client will be a happy client. If a user knows that you are working on the problem, they will mostly show patience as they know they are your current priority.

Great technical support does not end there. Once the problem is resolved, contact your client after a few days and ask if everything is working. This is the last step to a happy client. This helps in keeping the communication channel open.   

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This weekend, experts in internal medicine from around the world will convene at the American College of Physicians’s (ACP) Annual Meeting held Apr 28 – May 2, 2015, at the Boston Convention and Exhibition Center. The event garners 6,500+ practicing physicians and delivers scientific research and opinions designed to advance the practice of internal medicine and various subspecialities across global health care systems. What's making this event even more special is the fact that it marks the ACP's 100th anniversary.

We welcome attendees to join us at booth #1249. See how SensiCardiac is dedicated to enhance the way physicians performs cardiac assessments to improve clinical decision making and patient safety. SensiCardiac is an innovative, cloud based solution to record, interpret and share heart sounds. Optimised for effective early diagnosis and record keeping of auscultation findings.

Visit the SensiCardiac booth: #1249

Follow the conversation on Twitter: @Sensicardiac and @ACPinternests with hashtag #im2015

Read more about SensiCardiac here.

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We frequently do get the question: What heart defects can SensiCardiac detect? The short answer is any structural defect of the heart that will create a murmur. The most common structural defect among children is a congenital heart defect (CHD) and is a structural defect presented at birth. In most cases this defect will be undiagnosed at discharge after birth. Common examples of CHDs include holes in the inside walls of the heart and narrowed or leaky valves. In more severe forms of CHDs, blood vessels or heart chambers may be missing, poorly formed, and/or in the wrong place.

Globally, every 100th baby is born with a CHD and is therefore the most common birth defect. Nearly 40,000 infants in the USA are born annually with CHDs. CHDs are therefore as common as autism. Between two and three million individuals are thought to be living in the United States with CHDs, with many of these individuals not being aware of it. Except for patient records, there's no other system in place to track CHDs beyond childhood. Due to improved care, the number of adults living with CHDs is increasing. The result is that CHDs are now the most common heart problem among pregnant women.

CHDs are still the most common cause of infant death due to birth defects. Nearly one in every four babies born with a CHD will need surgery or other interventions to survive. Most babies with a CHD will reach adulthood, but will face a life-long risk of health problems such as issues with growth and eating, developmental delays, difficulty with exercise, heart rhythm problems, heart failure, sudden cardiac arrest or stroke.

Although 15-20% of all CHDs are related to known genetic conditions, most causes are unknown. A combination of factors can lead to a CHD, but in most cases the damage is already done before most women know they are pregnant.

A structural defect of the heart can also be acquired later in life.Some infections and disorders that may lead to heart disease include:

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According to the American Academy of Family Physicians (AAFP) distinguishing between pathological and benign (innocent) cardiac murmurs is perhaps the most challenging aspect of a physical examination. It is recommended that patients with signs or symptoms of a pathological murmur should be referred to a cardiologist.

This is even more true when making decisions during a pre-participation, school, college or DOT physical. When making eligible and disqualifying decisions, it is important to follow current clinical guidelines. Practitioners are often under pressure to clear a person for a certain activity, or may rush the exam, because no symptoms are presented.

Benign (functional, innocent or physiological) murmurs occurs in the absence of a cardiac structural abnormality with no symptoms or family history. The S2 sound pulse has a normal, physiological split, best heard at the pulmonary and there're no clicks or gallops. The murmur is usually early to mid-systolic with a musical, vibratory, or buzzing quality. And it is soft, grade two or lower.

The next image shows the relative mid-range energy distribution of the average heart beat for a patient with a benign murmur. The relative energy levels for the S1/S2 sound pulses, early-, mid- and late systole and diastole are also indicated. Note the relative low energy levels within the early and mid-systolic region. Typical for a benign murmur.

 Innocent Cardiac Murmurs

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According to an article in the NY Times “a young athlete dies from a cardiac incident once every three days in the United States” (Hidden Threats to Young Athletes – May 11, 2013). Sudden cardiac arrest is the number one killer of young athletes and is typically brought on by a pre-existing, detectable condition that could have been treated. According to www.myoclinic.org nearly 360,000 sudden cardiac arrests occur outside of hospitals each year in the United States alone.

How could Sensi be used in pre-participation screening?

One of the key clinical findings to evaluate when screening athletes for cardiac defects are murmurs, to detect structural defects within the heart.

The American College of Preventive Medicine (ACPM) supports an evaluation prior to participating in high school and college sports using a history and physical assessment as developed by the American Heart Association[1]. This assessment includes 12 criteria for pre-participation cardiovascular screening of competitive athletes:

Personal History

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A recent study at Johns Hopkins Hospital in Baltimore, Maryland, showed that cardiology residents were not able to identify 25% of the pathological murmurs presented to them.

How confident is a primary care clinician in identifying and classifying cardiac murmurs? To answer this question, two professions within the primary care sector were surveyed with the help of www.teamcme.com. Altogether 45 physicians (MDs) and 160 chiropractors (DCs) were surveyed. Both groups perform physical assessments as part of their daily routine and see the same population groups (See Figure 1).

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Figure 1: Physical assessment services offered by MDs and DCs.

  How often are primary care clinicians confronted with cardiac murmurs?

Identifying S1/S2 and hearing a cardiac murmur are the first steps in classifying a murmur. Although they frequently perform cardiac auscultation, chiropractors indicated that they very seldom hear a cardiac murmur (more than 50%). Only 1,3% indicated that they do hear a cardiac murmur frequently.

Is this due to an absence of cardiac murmurs in their patient population?

Physicians hear cardiac murmurs more frequently, 24,4% indicated frequent to very frequent, but still a bigger percentage indicated that they hear a murmur seldom to very seldom (35,6%).

How confident are they in classifying the murmur?

Classifying cardiac murmurs accurately is a skill that takes years to master. Confidence in cardiac auscultation is built by frequently using a stethoscope and being exposed to heart murmurs. More than 30% of the physicians interviewed indicated that they are confident with their ability to distinguish between innocent and pathological cardiac murmurs, while 46,7% rated their confidence as average.

67,5% of chiropractors rated their confidence as limited.

Can this have a direct impact on the quality of their service?

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Figure 2: The relative frequency with which MDs and DCs are confronted with a cardiac murmur. 

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Identifying extra heart sounds while auscultating is very challenging. Especially in relation to the third (S3) and fourth (S4) heart sounds.

The third heart sound is very common in children and even in people under 40, but later in life it is an indication of serious problems, like heart failure, and only appears when the problem is relatively far advanced. In some cases the third heart sound may never be heard, due to chest size, obesity or lung sounds, or due to hearing constraints of the listener. Therefore, the absence of a third heart sound does not exclude ventricular dysfunction or volume overload.

The low intensity, very low frequency and small audible area challenge clinicians auscultation skills and in most cases the third heart sound falls outside the human ear’s audio range.

The ability to detect and monitor third heart sounds in older patients is very important as this is associated with heart failure.

Hearing skills of trained cardiologists were recently compared with Sensi. Results confirmed that Sensi detected and indicated the third heart sound in cases where the human ear could not detect it, as well as in cases where the human ear detected the sound. This confirmed the importance of having a tool to assist in identifying extra, impossible-to-hear, heart sounds.

The next two figures show heart sounds recorded at the APEX. Figure 1 shows the presence of a very subtle S3 sound while Figure 2 indicates a prominent S3 sound. In both cases Sensi was used to visually confirm the presence of an S3 sound. S1, S2 and S3 annotation were added by hand.

 

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Figure 1: Subtle S3 sound.

Although very small, a S3 sound pulse is present in the consecutive heart beats shown in Figure 1.

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Less than 50% of the people that suffered from rheumatic fever are aware of it. This could have  devastating effects  later on in life.

Diacoustic Medical Devices is proud to be part of the SUNHeart Project at Stellenbosch University and Tygerberg Hospital’s Cardiology Department where about 2 000 learners from Khayelitsha and Ravensmead are currently being screened for possible heart defects.

Africa has one of the highest prevalences of heart disease in children and young adults, including congenital and rheumatic heart disease, and there is an urgent need to improve access to early diagnosis and treatment for patients.

Children in the age group 6 to 21 have the highest risk of throat infection, a cause of rheumatic fever. According to Prof Anton Doubell, Head of Cardiology at Stellenbosch University, many sufferers of the disease are only diagnosed with heart defects later in life, especially during pregnancy.  

During the eight-week SUNHeart Project each child will undergo a physical examination, heart sound will be recorded and analysed with SensiCardiac to detect abnormal cardiac sound, and each child’s heart will be screened with a hand-held echo, as well as a traditional sonar.

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