Tele-electrocardiography in South-East Asia Archipelago: From a Basic Need for Healthcare Services to a Research Implementation

Abstract

The fundamental principle for telemedicine implementation in the real world is to address the basic needs of healthcare services. The utilization of telemedicine naturally aimed to overcome distance, time, and financial constraints. Remote areas that are far from the cities and healthcare centers are the main regions that would mostly get benefit from the telemedicine program, for instance, in Indonesia, a country with a big archipelago area in South-East Asia. The primary healthcare center in this country is commonly available, however, the facilities and health workers are still limited. The health services are being centralized in big cities, and thus, the rural areas are far left in the context of healthcare services. Telemedicine could bring both standardized and specialized healthcare services nearer to the patients, irrespective of distance and location constraints. After receiving professional cardiology advice, implementation of telemedicine program, such as tele-electrocardiography (tele-ECG) at the primary care level, may be a financially advantageous way to identify cardiovascular disease in the general population and avoid overtreating patients. This is our first time adopting tele-ECG consultations in East Indonesia under the Makassar Telemedicine Program. This program allows us to maintain a big database of cohorts and connect its implementation to real-world clinical practices, and at the end, could guiding the health workers to improve patient’s outcomes.

1. Introduction

Telemedicine, a term that appeared in the 1970s, literally means “healing at a distance” [1]. In order to improve the health of people and communities, the WHO defines telemedicine as “the delivery of healthcare services, where distance is a critical factor, by all healthcare professionals, using information and communications technologies for the exchange of valid information for the diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and the continuing education of healthcare workers” [2]. As defined by the WHO, telemedicine is a system utilized to assist the healthcare functioning, especially healthcare services, education, research, and even training. The need for telemedicine is basically due to obstacles in optimizing the function of healthcare, particularly in poor-resource populations; either due to the large costs, long-distance barriers, limited human resources, the need for immediate or 24-hour services, as well as the nature of wide-spread coverage area of telemedicine [3].

The fundamental rule for managing a telemedicine program in a low- and middle-income country (LMIC) like Indonesia is whether the system can address the unmet needs for primary care services, how to deal with budgetary issues, how to empower the locals to use telemedicine, and most importantly, how to maintain and sustain the utilization for a long period of time [3]. This is often seen to be a problem or miscommunication between telemedicine-service providers who generally rely on the sophistication and completeness of the equipment, while the users on the other hand, simply ask for user-friendly devices. Unsurprisingly, the mismatch between providers’ capability, supporting infrastructure, and user needs, not rarely ends up with suboptimal function, and even worse, telemedicine is not working at all [4].

2. Tele-electrocardiography in low- and middle-income countries

Electrocardiography (ECG) is one of the daily needs of healthcare services, guiding the healthcare providers such as general practitioners (GPs), nurses, and even specialists to advance their diagnosis for patients with cardiovascular complaints [5]. The use and interpretation of ECG could be challenging, especially for health workers in suburban and rural areas such as Indonesia. Moreover, the need for real-time and quick decision-making for diagnosis and treatment for patients with acute cardiovascular disease (CVD) will enforce the use of tele-ECG in limited-resource LMICs. However, the available experts to interpret the ECG, the obligation for 24/7 service and quick answers are inevitable aspects of tele-ECG, and thus, considering these important aspects is crucial to implementing tele-ECG programs in LMICs.

Tele-ECG has evolved before, during, and after this pandemic era. The tele-ECG has been instrumental in reducing the un-need patients referral and has allowed better allocation of resources through early triage of patients with acute CVD, based on their symptoms and examinations. Our previous study showed that 100% of ECG recordings were transmitted successfully and qualified for analysis; and thus, we suggest that tele-ECG can be implemented in Indonesian primary care settings with limited resources [6]. In traditional manner, when tele-ECG program was not applied, the ECG solely interpreted by the GP in the primary care center; or even worse, the ECG are not available as a basis healthcare service in several primary centers. By implementing this tele-ECG program, the consultation to the expert cardiologists may assist the GPs for immediate triage, resulting in a higher rate of early hospitalization for indicated patients, and eventually could reduce the mortality rate of acute CVD in Indonesia [6]. The flowchart of utilization and final purpose of tele-ECG is shown in Figure 1.

Figure 1.

The utilization and final purpose of tele-ECG program.

The implementation of telemedicine in LMICs may not encounter many obstacles as long as it is correlated with the needs of healthcare services, as it is fundamental to healthcare function. The first implementation of this tele-ECG program was commenced before the Covid-19 pandemic. At that time, all patients with cardiovascular risk factors who came up to the primary care centers were screened using the tele-ECG. During this pandemic era, this tele-ECG is even more useful and practical to screen and stratify the patients with cardiac symptoms. This tele-ECG guides the GPs to determine which patients need a referral to the cardiac center, and which ones need enough observation and therapy in the primary level.

What about the research aspect? Is telemedicine program appropriate to be carried out in that direction? We agree that clinical research is important to get a big picture of the current situation of cardiology clinical practice, valuable to help analyze the real health problems and offer possible solutions to those problems. This is an interesting challenge in finding a way to implement and couple the telemedicine program with a research function.

The main principle in clinical research is that we get as much data as possible that represented the real population. The wide coverage of tele-ECG and the capability of providing big data allows the tele-ECG program as a preferable platform for conducting research. Based on our experience, conducting clinical research in LMICs is rather “exhausting.” Local researchers are forced to start everything from the scratch. Unavailable standard systems for reliable databases as well as limited resources and infrastructure also contribute to the low interest and awareness of carrying out clinical research in LMICs. Figure 2 presents the primary care nurse performing tele-ECG consultation and contributing to a cornerstone database of tele-ECG in Indonesia.

Figure 2.

Tele-ECG consultation from the primary care center.

With 17,508 islands and a population of more than 260 million, Indonesia is the most populous country in South-East Asia and the biggest archipelago in the world [7]. Java is home to more than half of Indonesia’s population, with the remaining residents dispersed throughout 6000 islands [7, 8]. About 11% of the Indonesian population living in a poor socio-economic level [9]. The leading cause of mortality in this lower-middle-income country, accounting for ~37% of all fatalities, is cardiovascular disease (CVD) [9]. Despite the high burden of CVD in this country, there were only 1.5 cardiologists available per 1,000,000 people in 2016 [9] and only ~30 cardiac facilities (half of which located in Java) were available in 2013 to treat the >2.6 million prevalent cases of CAD [10, 11].

Especially in remote areas, including in some peripheral areas in Indonesia, where human resources, i.e. nurses, general practitioners, and specialist doctors are rarely available, health equipment and medical facilities are also generally inadequate and not evenly distributed. As is well known, the remote island is an area with very minimal use of technology and with all its limitations, which becomes a challenge in implementing telemedicine in archipelagic areas [12]. On this occasion, the author used the tele-ECG program as a platform to answer the challenges of implementing telemedicine in archipelagic areas, and more specifically to obtain a reliable database in terms of research function.

3. Implementing telemedicine in the archipelago region: what’s the problem?

Remote islands in archipelago countries are areas that are suitable for the concept and purpose of the telemedicine program. These areas commonly live in poverty with poor health services, and urgently need assistance in solving the local health problems. To this end, telemedicine services should be utilized as routine healthcare services and function in daily practice. However, there may be challenges to run this program. In most remote areas, the healthcare officers are those with a lack knowledge and are not used to using modern technology. Mostly, medical devices in remote areas are also less modern and do not support modern application systems. In addition, in terms of infrastructure, internet signals in archipelagic areas are below average, using a low bandwidth category, and thus, a complex and sophisticated computer application in implementing telemedicine should be avoided [12].

In most LMICs, particularly in rural areas, the healthcare infrastructure is generally minimal or even unavailable, and local residents not rarely used traditional, instead of evidence-based medicine. Healthcare facilities for both diagnosis and treatment are almost blunted [13]. Based on the Speedtest Global Index, Indonesia is a country with the slowest average internet speed in Southeast Asia. As of December 2021, the average speed of mobile internet in Indonesia is only 15.44 Mbps, with the upload speed of about 9.16 Mbps, and the latency is 28 ms.

4. Telemedicine and research

The Makassar Cardiac Center launched the first telemedicine initiative in Eastern Indonesia in response to the dearth of cardiologists and the obvious demand for competence in cardiovascular treatment. With the use of this service, primary care centers can send electrocardiogram (ECG) data to Hasanuddin University Hospital. In this program, primary care GPs immediately received expertise from cardiologists when dealing with patients with CVD symptoms or risk factors. Despite the fact that Indonesia began implementing the telemedicine program in 2012, reporting on the initiative’s effectiveness and results has not received as much attention.

Although telemedicine system is also developed for research functions, it is realized that research stuff is merely invaluable for the users. Primary healthcare centers and sub-health centers will certainly not be interested at all in the research objectives, especially for health workers who work on remote islands. Research appropriation is not the main issue in healthcare services in remote areas. The first and foremost is, whether the large and extensive data can be obtained through telemedicine services to improve the quality of care and clinical outcomes of patients in remote areas.

5. Telemedicine in archipelago countries: the concept of solutions

Looking at the telemedicine systems that are currently being run and developed, on average, the telemedicine system needs sophisticated technology, such as teleradiology that uses DICOM-based PACS. The telemedicine system requires modern equipment and high-speed internet with high bandwidth, which is expensive. On the other hand, to maximize telemedicine utilization, the users also should be familiar with high-tech applications. Unfortunately, these requirements are incompatible and difficult to be fulfilled in archipelagic or remote areas. Encountering these challenges and limitations, innovation and creativity are needed in designing and making an ideal and compatible telemedicine model in the archipelagic area [4, 14, 15].

The author hypothesizes that technology is flexible and can be customed to meet the local field conditions, including in extremely difficult archipelagic areas. The concept design of archipelagic telemedicine should be cheap, user-friendly and transmittable, and feasible. The design of the telemedicine system design is also should be easily utilized for the research purpose by providing reliable big data, altogether with appropriate data processing facilities, thus could be used for research and educational purposes.

6. Role model of tele-ECG in Eastern Indonesia

Electrocardiography examination requires an electronic medical device called an “electrocardiogram” [5]. There are various types of tools based on the development of the system: some have DICOM-based-high-technology which is easily integrated with the current developed modern application systems, and some others are less modern and still based on non-DICOM and difficult to be integrated directly with tele-applications [4, 16, 17, 18].

In LMICs, including in Indonesia, the majority of available ECG tools is a non-DICOM-based devices. The developed tele-ECG application model will take the ECG image indirectly from the machine, and then will be stored in pdf format, as long as the ECG device has a program that could produce the output that is connectable to the computer storage, with the average size of files is less than 2 MB. This small file size is very suitable and easy to be transmitted in unstable internet speed or low-bandwidth conditions in LMICs, particularly in remote archipelagic areas. An application model with a display of the ECG image equipped with the result description on one screen will make the interpretation process by expert doctors easier.

The results and description of the ECG were made in a form of multiple choice with a point-to-point-click checklist, and thus the users will no longer need to type descriptions and conclusions of those ECG recordings. The users just need to choose the description that had been provided. The available description patterns are made by default for normal results. For example, for normal ECG results, the expert doctors only need to fill the heart rate column, to optimize the data storage. Each selected description will be ready as the standardized data that have been completed with the description with the smallest file size and will be directly stored in the database that could be easily recognized by the system. Figure 3 shows the tele-ECG application that has been used for Makassar Telemedicine Program that provides services for 46 primary care centers distributed in urban, rural, including remote islands in East Indonesia.

Figure 3.

Tele-ECG application used in Makassar Telemedicine Program that provides services for 46 primary care centers in Indonesia.

7. Implementation of tele-ECG model in Makassar, Indonesia

The implementation of tele-ECG at more than 46 primary care centers in Indonesia has started in 2015, mainly in the South Sulawesi Province. Each primary care center provides tele-ECG services, not only for outpatient clinics but also for Emergency Department. The tele-ECG consultations were carried out for all patients with suspicion of heart disease, including acute coronary syndrome.

Makassar tele-ECG service runs routinely every day, with around 10,000 cardiac records have been transmitted in 4 years since its commencement. During the operation, every transmitted ECG record would get a quick response from the cardiology consultant. For the clinic services in primary care centers, on average, the ECG recordings were sent from morning to afternoon, and subsequently, the response and answers by the consultants would be delivered within 2–4 hours. In the case of acute or emergency settings, the operator will immediately notify the consultant for an immediate response. For normal ECG, the consultant only took 15 seconds to make the description of ECG. Meanwhile, for an abnormal ECG, the average time needed to describe the ECG was about 30–45 seconds. The tele-ECG answers can be immediately seen by the sender, i.e., nurse or GP at the primary care center, with available printable reading results when needed.

8. Data collection and measurement

Using an automated ECG equipment—the BTL-08 SD ECG (BTL Industries Ltd., Hertfordshire, United Kingdom)—trained primary care nurses collected patients’ ECGs. The Hasanuddin University Hospital’s analysis service center received the ECG files through the internet and stored them in the hospital’s database. All of the ECG recordings were reviewed and examined by two cardiologists. Between August 2015 and February 2018, Makassar Telemedicine Service (MTS) received ~10,000 12-lead ECG recordings from patients in primary care.

In order to gather information on sociodemographic and clinical profiles (such as symptom, onset, prior disease, prior medication, anthropometric status, vital signs, and cardiovascular risk factors: hypertension, diabetes mellitus, current smoking, and family history of CVD), management and medications after tele-ECG, and GP’s reasons for and satisfaction with tele-ECG consulting, a thorough questionnaire was developed. All participants had vital sign assessments, including blood pressure, heart rate, respiration rate, and axillary temperature, as well as anthropometrics, a routine physical examination, and ECG analysis. Manual measurements were taken for height, waist circumference, and body weight. Since these tests are typically not accessible at the primary care level, none of the laboratory tests—such as fasting plasma glucose, lipid profiles, and creatinine—was carried out. All these data were collected in a standardized database. The data were then converted into Excel format for further analysis in the SPSS statistical program for research purposes.

9. Implementation results: the first report from the tele-ECG program in Indonesia

A total of 10,001 ECG recordings were transferred to telemedicine program’s analysis center at Hasanuddin University Hospital between 2015 and 2018. All ECG recordings were eligible for analysis. Around 73% of the overall ECG recordings were classified as normal. After ECG categorization, ischemia was discovered in 13% of cases, arrhythmia in 18%, and structural abnormalities in 5%. Table 1 displays the analysis and distribution of all ECGs from the Makassar Telemedicine Program (n = 1001), while Figure 4 shows the ECG abnormalities based on gender and age.

Classification	ECG patterns*	Total (n = 10,001)
Normal ECG	Normal sinus rhythm	7265 (72.6)
Ischemia	ST-elevation myocardial infarction	98 (1.0)
	Old myocardial infarction	548 (5.5)
	ST and/or T wave changes suggestive of MI	509 (5.1)
	Non-specific ST and/or T wave changes	99 (1.0)
Arrhythmia	Sinus bradycardia; Sinus tachycardia; Supraventricular tachycardia; Atrial fibrillation; Atrial flutter; Atrial premature complexes; Ventricular premature complexes; Sino-atrial block; Atrioventricular block; Right bundle branch block; Left bundle branch block	892 (8.9); 393 (3.9); 11 (0.1); 110 (1.1); 9 (0.1); 94 (0.9); 105 (1.0); 6 (0.1); 49 (0.5); 160 (1.6); 21 (0.2)
Structural change	Left atrial enlargement	45 (0.5)
	Right atrial enlargement	48 (0.5)
	Left ventricular hypertrophy	418 (4.2)
	Right ventricular hypertrophy	23 (0.2)
Others	Early repolarization; Left axis deviation; Right axis deviation; Hyper/hypokalemia	72 (0.7); 184 (1.8); 128 (1.3); 37 (0.4)

Table 1.

Interpretation of ECG recordings from Makassar telemedicine service.

*

More than one ECG diagnosis per patient is possible.

Values are n (%).res.

ECG = electrocardiogram; MI = myocardial infarction.

Figure 4.

Distribution of ECG abnormalities based on gender and age.

Our previous study shows that tele-ECG consulting was helpful to support GPs in primary care in making a quick decisions on patient management. Of 10,001 ECG screenings transmitted to the analysis center, 100% qualified for analysis.

Implementation of the tele-ECG program during these 4 years showed that the delivery process run smoothly, as there were always 5–10 tele-ECG recordings transmitted from several primary healthcare centers every working day. The succession of this implementation is supported by the local government provided the infrastructure; trained nurses and GPs who made the first screening and risk stratification; and immediate response of the expert, cardiologists to read and answer the teleconsultation. This fact showed a piece of robust evidence that the design and model of the tele-ECG program that prioritized the easiness for both the senders and readers and smooth internet connection had been successfully implemented in the archipelagic areas.

In view of cardiology services, 88 patients for whom hospital admission was advised, 72 (81.8%) were immediately referred within 48 hours following the tele-ECG consultation. Thus far, this tele-ECG program has been successfully carried out with two main purposes, healthcare services, and research, that ultimately help in improving patient outcomes.

SVT, supraventricular tachycardia; AF, atrial fibrillation; Aflut, Atrial Flutter; AES, atrial extra systole; VES, ventricular extra systole; S-A block, sinoatrial block; A-V block, atrioventricular block; RBBB, right bundle branch block; LBBB, left bundle branch block; STEMI, ST-elevation myocardial infarction; Old MI, old myocardial infarction; LAE, left atrial enlargement; RAE, right atrial enlargement; LVH, left ventricular hypertrophy; RVH, right ventricular hypertrophy.

10. Conclusions: philosophy of tele-ECG implementation

• Telemedicine program is about function, not sophistication. And thus, placed the tele-ECG program in the areas where it is needed the most.

• The main goal of telemedicine in archipelagic areas is not about healing the patients’ disease, but beyond this, concern and sustainability.

• When technology is in hand, while the natural conditions are out of reach, then technology follows nature.

• The basis of telemedicine research is healthcare services, therefore, addressing the service function first and patients data would follow the way.

Acknowledgments

The participants in Makassar’s primary care centers are warmly acknowledged for their willingness to take part in this tele-ECG program. We also thank the patients’ advisors and family members for their participation and support. We appreciate Makassar City’s municipal government’s assistance in putting tele-ECG into daily practice. We also thank the employees and residents at Pusat Jantung Terpadu Makassar Cardiac Center for their contributions to the accomplishment of this telemedicine project. We acknowledge all research assistants, primary care nurses, cadres, and personnel that helped with data administration for this study.

Conflict of interest

The authors declare no conflict of interest.