We have described a routine telecardiac consultation service limited to clinical data and tele-electrocardiography assessment. When incorporated into a comprehensive, non-invasive telecardiac consultation service including tele-echocardiography, this
approach can be expected to change significantly both the priorities and the mode of assessment of cardiac patients in primary and secondary health care. Compared with primary-care consultations, referral of patients to a secondary-care facility for consultation is always more alarming and time consuming for the patient, interfering with his or her normal routine while also deferring decision making and imposing an additional heavy cost on the supplier of health-care services.
Cardiovascular disease remains the leading cause of morbidity and mortality in developed countries, while health services in these countries are experiencing a number of conflicting influences. Developments of technology and imaging techniques have greatly increased diagnostic powers. These developments have been well publicized, creating widespread awareness of
them among both the general public and patients. Additionally, government initiatives such as the Health of the Nation policy in the UK have increased public expectations, not only for high-technology health care but also for rapid, unimpeded access. On the other hand, hospital diagnostic facilities have expanded slowly while the debate regarding the future funding and provision of health services continues. With the rapid expansion of medical knowledge in all disciplines, it is unrealistic to expect that the individual primary-care physician can keep abreast of all developments and diagnostic procedures alone. However, through the effective use of technology and existing highly trained medical personnel, GPs' diagnostic services and patient-management capacity can be enhanced, such that they can satisfactorily assess and treat patients at the primary level, accurately identifying those who require referral for consultant opinion and intervention. Telemedicine facilitates realtime discussions between physicians in primary and secondary care. It is this ability to overcome the problems
of accesst hat makes the technique so potentially useful Currently many GP practices in the UK are devoid of ECG equipment, seldom make use of equipment, have inexperienced interpreters, or demand expert knowledge and advice. ECG recording by GPs in isolation has failed to improve the specificity and sensitivity of the referral process. As an alternative, the local hospital may offer a direct-access ECG service. This requires that the patient visits the hospital at least
once, perhaps after a wait of days or weeks, and must return to the GP some days after the recording has been made, following reporting by a hospital doctor and mailing of the report back to the GP. In the light of the report, the GP then decides whether to refer the patient to an outpatient clinic. A referral involves a letter which must pass through the hospital's outpatient registration system until a decision is made regarding the hospital's perception of the urgency of the matter. Discussion between the GP and the hospital consultant is relatively rare. It is not uncommon that when the patient is eventually seen, it is decided that it is a relatively minor matter which should be dealt with by the GP. Our experience has shown that patient evaluation time is cut considerably when there is discussion of the case with a hospital physician who is able to see the ECG. Simple problems can be dealt with over the telephone and agreement reached regarding a management strategy which, in many cases, obviates the need for patient referral. At the same time the patient has had
ready access to specialist expertise without having to leave the primary-care setting. In our study the GPs' responses to the questionnaire indicated that this consultation service had obvious advantages over the well established transtelephonic ECG stand alone' technique. The direct-access service increased GPs' confidence following verbal consultation and offered an opportunity to alter and improve the management of cardiac patients in their practice instead of unnecessary referrals to accident and emergency departments. GPs also indicated that the service enhanced the doctorpatient relationship. The telecardiology service can accurately identify patients with urgent problems requiring rapid assessment at the hospital or even emergency admission. The system is portable, so that it can be used in patients' homes, facilitating the emergency evaluation of chest pain. In a number of cases, we have been able to diagnose acute myocardial infarction, arrange immediate transfer to hospital and begin thrombolytic therapy within a few minutes of arrival. The backbone of the service was provided by cardiology registrars, who were all experienced in cardiology and had ready access to consultant support
in doubtful or complicated cases. Where appropriate, the consultant was able to speak directly to both patient and GP. Both GPs and patients expressed their complete satisfaction and confidence in the quality of consultations throughout the trial.
Although no accurate financial analysis has been carried out, simple computations can be used to estimate the cost-effectiveness of this project. The approximate cost of employing a consultant for an hour in the National Health Service is L25, whereas a registrar costs f ,12.50 per hour (f,1 is 1.20 ECU or $1.57). A typical initial outpatient consultation would
take 30 minutes. By comparison, a telecardiac consultation would involve the hospital physician for only about five minutes. This reduces the physician costs by some 80%. In addition, a patient's referral to the hospital involves clerical and secretarial costs relating to the appointment bookings, schedules, file management and reception duties, followed by a letter of consultation for the GP. This cost is of the order of €,20. Support of 26 primary-care centres involved an initial investment in hardware and softwaqe of about L20,000. This included computer equipment, telecommunications and ECG monitoring equipment for 93 GPs, which averaged L770 per practice, or 186 per GP. Management costs were minimized as the service was run by the cardiology firm with registrars on duty sharing the on-line consultations. However, a staff nurse or a cardiac technician was required to service the CMC for data acquisition, ECG measurements and reporting. The further operating costs of the service, excluding salaries, have been estimated at about L2 per consultation for telephones, printing and postage. Extension of the service by the incorporation of remote echocardiographyis possible by use of the ISDN. Although currently expensive, ISDN 30 allows the transfer of realtime images at an acceptable frame rate. Using this technology, the hospital physician can participate in an investigation carried out in the practice, probably by a technician, by giving directions
and comments. Immediate recommendations would be available to the GP with regard to patient management. In developed countries, this is likely to find greatest application in the assessment and management of patients with known or suspected cardiac failure, the one area of cardiology where the prevalence of a condition is increasing. There is now good evidence of the value of treatment with angiotensin-converting enzyme (ACE) inhibitors in improving both prognosis
and quality of life. Figures suggest that these drugs are underused in the community and that some GPs are reluctant to initiate this treatment without hospital support. We conclude that a telecardiology diagnosis and ECG interpretation service is simple, reliable and efficacious in routine orimarv care. It offers instant access to cardiac assessment and supports GPs'
decision making. It results in early detection of heart disease, on-line assessment of suspected acute events, adequate filtering and priority grading of referrals for patients requiring further investigation while reducing the load of unnecessary referrals for primary diagnosis. The telecardiology study reported here was based on ranstelephonic communication and transmission of clinical and ECG data. It was part of a study of comprehensive telecardiac assessment services for primary
health care incorporating a tele-echocardiography service and may pave the way for the development of similar services for primary health care in other disciplines.

Acknowledgements: We thank NCMC Ltd (London HA8 OAD) and the manufacturers of the transtelephonic ECG equipment, Aerotel Ltd (5 Hazoref Street, Holon, 58856, Israel), for their assistance

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