This report originally appeared in the January 2010 issue of DOTmed Business News.

EKG or ECG: Which Is Right?
Read a related feature at
https://www.dotmed.com/news/story/10971




Cardiac monitoring is a business that keeps pumping along at a regular beat. EKG and holter monitors are essential toolkit technologies for primary care as well as cardiology practices and hospitals.

"Business is pretty steady. EKG is like a stethoscope. Internal medicine and family practice can't get around having one. Even though reimbursement has gone down and they are basically doing it for free these days, they must have it," said John Gladstein, sales manager, Medical Device Depot, Ellicott City, Maryland. His company is a new equipment distributor founded in 2008. They offer EKG and holters from the top manufacturers including Cardiac Science Corporation (the Burdick brand), GE, Midmark, Philips, Swiss maker Schiller and Welch Allyn. "This equipment is important to the standard of care and that keeps the market going," Gladstein said.

"The market is steady with moderate growth. It is a tried and tested business and a first-step modality - so physicians would do a 12-lead ECG and then a holter," said Meera Gopalakrishnan, product manager, ambulatory ECG, Philips Healthcare. "There is a lot of physician confidence in the modality."
Centered


New advancements in these workhorse monitors are mostly geared toward digital innovations that provide connectivity to PCs and electronic records, bringing some high-tech features into nearly any practice setting.

"The trends these days are connected devices with physicians utilizing electronic health records (EHRs). We all know about the stimulus act freeing up money for physicians to get involved with EHRs," said Steve Kenan, Welch Allyn senior category manager for cardiopulmonary. "A big part of utilizing an EHR is utilizing connected devices. So connectivity, being able to transmit data bi-directionally between a device and the EHR, has become the number one topic in the industry."

"We find a lot of cardiology offices have just as sophisticated systems for doing holters as hospitals," said Boyd Campbell, principal, Southeastern Biomedical Associates, Granite Falls, N.C. "Several of our customers have remote sites; some cardiology offices have a half dozen offices networked together. That is different from what we used to call 'sneaker net,'" he reflected. His company, established in 1996, is a distributor for GE Healthcare in the non-hospital market; and for Cardiac Science in the hospital market. "In the past you would take a holter somewhere to be read, then hand-carry results. Now we're able to do it via the internet or a network between remote locations. It speeds the time to get results to the patient," Campbell said.

While cardiology may have lagged behind radiology and PACS in entering the digital age, the field is catching up in ways that promise to change the way care is delivered not just at doctors' offices, but also in hospitals. Traditional stand-alone EKGs are used in ER and cardiology departments, while multi-parameter continuous patient monitors are found by the bedside.

"What's exciting is all the devices we currently market for our continuous monitoring portfolio have a wireless option," said Bill Quatier, category manager for acuity and wireless at Welch Allyn, the near century-old innovator that holds numerous patents in monitoring and other medical technologies. "A decade ago, if someone was very sick, we moved them to the monitored room. As they got better, they were transferred to a room with not quite as many monitors. Eventually they could go down to a floor without that monitoring capability. That's all changed. With wireless technology, we can take a monitor with a patient no matter where they go."

This seemingly simple shift has tremendous implications for the quality and cost of care since patient transport costs and associated risks (such as infection) are eliminated.

"We realize that today, patients that used to be seen in ICUs might be seen in private rooms on a regular floor because monitoring has improved and health insurance has driven costs such that people need to be cared for in lower acuity and therefore lower-cost settings," Quatier said.


Meanwhile, in many ERs traditional stand-alone EKG monitors are often pressed into service, resulting in some challenges in these hectic settings.

"We have discovered that in the rush of an ER situation, the EKG units are handled more roughly," said Dean Johnson, partner, BioTech Services, Inc., Edgerton, Wisconsin, a two-year-old service company. "When I look at histories of EKG units in our database, I can see those used in a diagnostic situation or cardiac rehab rarely have a problem. Those in an ER will have the same problem and need repair three or four times a year. It's the nature of the work."

Typical Repairs

From the biomedical engineer perspective, EKG monitors require predictable, regular repairs.

"Typically the PM (preventive maintenance) doesn't find much wrong. We replace batteries on a regular basis because they can be away from an outlet and go dead. We clean the printheads, make sure the printer drives are working, and check physical integrity and electrical safety," Johnson said. "The problems with the machines almost entirely happen in use. The most common things are failure to get a proper signal or for the signal not printing out. The thing we often work on is cabling."

Johnson and other engineers suggested that users take care not to roll equipment over cables and leads and to avoid crimping or wrapping them around the cart leg or handle when storing the equipment. Be gentle to avoid equipment or cabling breakdowns.

"Leads and accessories are the biggest issue. They are tugged, run over, bent, and not properly stored. If care is taken with lead wires, it avoids many issues and saves money," noted Justin Jeffries, COO of DRE, Inc. The Louisville, Kentucky firm provides a combination of new and professionally refurbished equipment. (They recently came out with a new multi-parameter vital signs monitor, see DM 10355.) "Be careful to not place the machine in a situation where items could fall or spill on the display screen," Jeffries added.

Continuous patient monitors require additional attention to CRT tubes,
LCD displays, backlights, driver boards, screens and cases.

As with many other medical technologies covered by DOTmed, industry watchers report that, health care providers are slow to buy new EKG and patient monitoring equipment lately, increasing demand for good service solutions.

"People are biding their time till they can get the new monitoring systems, keeping the old stuff running as long as they possibly can," said Michael Mohs, Biomedical Services Coordinator for DMS Topline Medical. A division of DMS Health Technologies, DMS Topline Medical provides reconditioned patient monitoring and other equipment.

Mohs noted that the parts business is growing in the EKG market. "With today's economy, people aren't ready to buy new so we are seeing a big upswing on parts," he said.

New Equipment Innovations

Surprisingly for this rather unsung area of technology, several impressive advances have come to market of late.


In 2008, Philips introduced its DigiTrak XT Holter Monitor, an amazingly small unit that looks like a cell phone worn on the belt.

"We used workflow features that are common in everyday life and adapted them to medical technology so the consumer doesn't see the difference. It blends seamlessly," said Philips' Gopalakrishnan.

Using just four patient leads (plus ground) the unit reports the equivalent of 12 leads of derived ECG data. Proprietary algorithms in PC-based software provide excellent clinical decision support. The device is extremely easy to use with a lead map displayed for the technician right on the unit. It will even auto-start if someone forgets to start the recorder.

Another promising breakthrough in holter is its application for sleep studies with the addition of a pulse oximeter and special software manufactured by NorthEast Monitoring.

"It's a holter monitor just like in cardiology. One way of accurately determining sleep apnea is to examine ECG levels corresponding to pulse oximetry," explained Garret Purrington, president, Medical Equipment Dynamics, Inc., New Bedford, Mass. The two-year-old company sells a variety of new and used medical equipment. "It's a great application because if you're an ENT facility or general practice you can send the patient home instead of sending them to a sleep lab which costs insurance thousands of dollars. The referring physician can pay the unit off quickly. It's a good reimbursement rate."

In the ECG space, Philips offers its latest product, the touch screen PageWriter TC-70 also known for super ease-of-use as well as advanced clinical decision support and workflow benefits.

"The technology has unique things to make patient care more effective and safer," said Kevin Geary, global product manager, Pagewriter Cardiographs, Philips Healthcare. It provides analysis of up to 16 leads instead of the usual 12, looking at a wider area of the heart including the right ventricle or posterior wall of the heart.

"If you go to the ER with shortness of breath [a vague symptom] and they put on a standard 12-lead, it won't find a heart attack in your right ventricle; it comes out normal," Geary said. "Because we look at the right ventricle and posterior wall, our equipment shows a positive ECG test." This might speed a patient to the cath lab for treatment before she suffers permanent damage.

Not to be overlooked are some low-priced new technologies from China including Mindray and Edan.

"It hurts the refurbished market a bit because you can get a brand new Mindray patient monitor for the price of a refurbished one. It comes with a two-year parts and labor warranty. If I were a doctor's office or surgery center, why would I buy a used monitor? It doesn't make sense," Purrington said. However, he noted that the need for compatibility with installed systems drives an ongoing used equipment market. "Refurbished [equipment] will always be strong because you've got standardization problems. You need to standardize patient monitors."

Edan Instruments, Inc., established in 1995 and located in Shenzhen, makes stand-alone and PC-based ECG monitors and other technologies.
"We are the first Chinese EKG supplier that received FDA clearance, Sales Manager Toby Hu writes to DOTmed. "Edan Instruments will set up our first U.S. branch office in San Diego in order to offer better support and service to our customers."

Watch for a report on Chinese medical markets forthcoming in DOTmed Online News.

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DOTmed Registered Monitor (EKG, Holter) Equipment Sales & Service Companies
Names in boldface are Premium Listings.

Domestic
Arthur Zenian, enBio, Corp., CA
Robb Edwards, Nihon Kohden America, CA
Andrew Bonin, Pacific Medical, CA
Gordon Huckestein, Cardiac Direct, CA
Dennis Vernon, Vail Medical Equipment Brokers, CO
Judy Engle, Frontier Medical Inc, CO
DOTmed Certified
Moshe Alkalay, Hi Tech Int'l Group, FL
DOTmed Certified
Don Hooley, DH Biomedical Inc., FL
David Joy, DataScope Multivendor Repair, FL
Clinton Courson, Quest Medical Supply, Inc., FL
Mario Goderich, ATI Medical Corp., FL
Debbie Benghuzzi, Bay Medical Equipment LLC, FL
DOTmed Certified
Michael Parnell, EquipStat Medical Equipment, FL
DOTmed Certified / 100
Stan Poole, Medical Maintenance Consultants, Inc., GA
Richard Fosco, HealthWare Inc., IL
DOTmed Certified
Justin Jeffries, DRE Inc., KY
Meera Gopalakrishnan, Philips Healthcare, MA
Kevin Blaser, Coast To Coast Medical, MA
Garrett Purrington, Meeical Equipment Dynamics Inc., MA
DOTmed 100
John Gladstein, Medical Device Depot, MD
DOTmed Certified
Asif Bhinder, Tekyard , MN
Matt Bion, Principal Medical, MN
DOTmed Certified
Terry Schulze, Biomedical Systems Inc., MN
Jason Eden, Bio Basics Global, MO
DOTmed Certified
Boyd Campbell, Southeastern Biomedical Associates, Inc. , NC
DOTmed Certified / 100
Scott Mancini, Martab Medical , NJ
David Ogren, OMED of Nevada, NV
Ralph J. Pesant, RJP International Inc., NY
Roger Nasiff, Nasiff Associates Inc. , NY
Abe Sokol, Absolute Medical Imaging Group, LCC, RI
DOTmed Certified / 100
Jennifer Rice Bielewicz, ScottCare, OH
Brent Davies, The Sentinel Imaging Group, Inc , MN
Bulent Buyukoglu, USmedevice LCC , RI
DOTmed Certified
Tom Boston, US Medical Systems , SC
Mike Davies, ProNet Medical, UT
Dean Johnson, BioTech Services, Inc., WI

International
David Richards, Treadmill Solutions, Canada
Toby Hu, Edan Insturments, China
Kelly Huang, Uni-tech Medical Supplies, Inc., China
Pierre Langlois, Berthelot, Broad and Better TV, France
Ghassan Melki, M.E.S.S. Sarl, Lebanon

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