title: Interpretation of remotely downloaded pocket-size cardiac ultrasound images on a web-enabled smartphone: validation against workstation evaluation.
abstract: BACKGROUND
  Pocket-size ultrasound has increased echocardiographic portability, but expert point-of-care interpretation may not be readily available. The aim of this study was to test the hypothesis that remote interpretation on a smartphone with dedicated medical imaging software can be as accurate as on a workstation.
  
  
  METHODS
  Eighty-nine patients in a remote Honduran village underwent echocardiography by a nonexpert using a pocket-size ultrasound device. Images were sent for verification of point-of-care diagnosis to two expert echocardiographers in the United States reading on a workstation. Studies were then anonymized, randomly ordered, and reinterpreted on a smartphone with a dedicated, Health Insurance Portability and Accountability Act-compliant application. Point-of-care diagnosis was considered accurate if any abnormal finding was matched and categorized at the same level of severity (mild, moderate, or severe) by either expert interpretation.
  
  
  RESULTS
  The mean age was 54 ± 23 years, and 57% of patients were women. The most common indications for echocardiography were arrhythmia (33%), cardiomyopathy (28%), and syncope (15%). Using the workstation, point-of-care diagnoses were changed in 38% of cases by expert overread (41% left ventricular function correction, 38% valvulopathy correction, 18% poor image quality). Expert interobserver agreement was excellent at 82%, with a Cohen's κ value of 0.82 (95% confidence interval, 0.70-0.94). Intraobserver agreement comparing interpretations on workstations and smartphones was 90%, with a Cohen's κ value of 0.86 (95% confidence interval, 0.76-0.97), signifying excellent intertechnology agreement.
  
  
  CONCLUSIONS
  Remote expert echocardiographic interpretation can provide backup support to point-of-care diagnosis by nonexperts when read on a dedicated smartphone-based application. Mobile-to-mobile consultation may improve access in previously inaccessible locations to accurate echocardiographic interpretation by experienced cardiologists.
authors.affiliation: Division of Cardiology, Department of Medicine, The George Washington University, Washington, District of Columbia, USA. bchoi@mfa.gwu.edu
authors.forename: Brian G
authors.initials: BG
authors.lastname: Choi
authors.forename: Monica
authors.initials: M
authors.lastname: Mukherjee
authors.forename: Praveen
authors.initials: P
authors.lastname: Dala
authors.forename: Heather A
authors.initials: HA
authors.lastname: Young
authors.forename: Cynthia M
authors.initials: CM
authors.lastname: Tracy
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Katz
authors.forename: Jannet F
authors.initials: JF
authors.lastname: Lewis
mesh_terms: D040421:Cell Phone; D004219:District of Columbia; D004452:Echocardiography / Q000295:instrumentation* / Q000379:methods*; D004867:Equipment Design; D019544:Equipment Failure Analysis; D005260:Female; D006331:Heart Diseases / Q000000981:diagnostic imaging*; D006801:Humans; D008297:Male; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D017216:Telemedicine / Q000295:instrumentation* / Q000379:methods*