2009 31: 550���552 SHORT COMMUNICATION Freeware eLearning Flash-ECG for learning electrocardiography KALLE ROMANOV & TIMO KUUSI Research & Development Unit for Medical Education, University of Helsinki, Helsinki, Finland Abstract Background: Electrocardiographic (ECG) analysis can be taught in eLearning programmes with suitable software that permits the effective use of basic tools such as a ruler and a magnifier, required for measurements. Aims: The Flash-ECG (Research & Development Unit for Medical Education, University of Helsinki, Finland) was developed to enable teachers and students to use scanned and archived ECGs on computer screens and classroom projectors. Results: The software requires only a standard web browser with a Flash plug-in and can be integrated with learning environments (Blackboard/WebCT, Moodle). The Flash-ECG is freeware and is available to medical teachers worldwide. Introduction Electrocardiography (ECG) is probably the most common laboratory method for examining cardiac health. In all like- lihood, the majority of many ECG recordings are interpreted by clinicians who are not cardiologists, which raises concerns about the exactness of these results, primarily due to a lack of sufficient training in ECG interpretation (Hurst 2003 Salerno et al. 2003). Today, internet technology enables the distribu- tion and educational use of realistic-looking ECG recordings to help improve the skills of clinicians in interpreting ECGs. However, an interface with static images on a standard web page is not optimal for examining ECG strips because the plain ECG recording in the form of an image file (jpg or gif) fails to allow the use of simple diagnostic tools, such as a ruler and a magnifier, for basic measurements. Our aim was to develop a software application that would resolve such limitations to the use of computer graphic technology by permitting the proper use of simple tools required for ECG interpretation. Material and methods The dynamic Flash-ECG permits the use of a pair of ECG strips (chest, limb) in electronic form with several interactive properties. In addition, another software solution for virtual ECG designed especially for the diagnostics of arrhythmias has been introduced (Criley & Nelson 2006). However, we are unaware of other applications, apart from our Flash-ECG, which would be freely available for medical teachers around the world. Our solution is based on the standardized Flash plug-in (Adobe Flash Player) in the web browser. With the Flash-ECG, learners can enlarge the ECG strip and make all measurements to achieve more relevant diagnostic information than with just the scanned ECG (Figure 1). Users can choose to display limb/chest leads, and with a virtual six second transparent ECG ruler, the strip can be analysed for various parameters, such as the duration of P, PQ, QT, QRS and pulse rate. The ECG rhythm strip and the ECG ruler can be moved using the left mouse button. The ruler drop menu returns the ruler to view if pushed out of the flash window and can be used to examine the strip. The magnifying glass, operated with the Flash-ECG magnify/contract buttons or with the mouse scroll-wheel, will increase/decrease the image size, and the left button of the mouse allows the user to move both the ECG and the transparent six-second ruler. (Figure 2 For measuring the pulse rate: place the ruler���s arrow in the upper-left corner of an R the linear scale at the top of the ruler will show the pulse rate at the third R. The middle linear scale shows the normal QT duration in relation to the pulse rate. The third linear scale shows a duration scale for measurements of one second with a sensitivity of 0.02 s. The scale at the left end of the ruler is to measure the ST segment depression with the J point. At heart rates 130, the ST segment depression is assessed using the dotted line below B at higher rates, the dotted line below A is used.) Results and discussion Teaching practical electrocardiography depends on having convincing, authentic-looking recordings. To produce learning material, a teacher needs only the original ECG and a scanner and a suitable method to publish the virtual ECG to the students, whose PC work-stations require only a standard web browser with the Flash plug-in. No special hardware equip- ment is needed to produce the material. We used a standard scanner and scanned the standard paper ECG strips at 300 dpi. The size of the colour original JPG image should be 3000 2200 pixels to be compatible with the Flash-ECG. The scanned jpg image can simply be dropped into the application folder. Correspondence: Kalle Romanov, Research & Development Unit for Medical Education, University of Helsinki, P.O. Box 63, FIN 00014 Helsinki, Finland. Tel: ��358-9-191 25050 fax: ��358-9-191 25139 email: kalle.romanov@helsinki.fi 550 ISSN 0142���159X print/ISSN 1466���187X online/09/060550���3 �� 2009 Informa Healthcare Ltd. DOI: 10.1080/01421590802415595

The Adobe Flash Player plug-in is needed for end-users to use the Flash-ECG. The correct scale of the chest and limb jpgs can be verified with the scale of the transparent ruler. The eECG was designed to be 100% compatible with major learning platforms like Blackboard/WebCT and Moodle. Consequently, the Flash-ECG can be published on any standard web page or in these learning environments, and it can easily be integrated with quizzes, exams, or further learning material, to provide feedback for learners. In other words, the eECG is predomi- nantly a supplementary application to enable students to learn ECG in various electronic learning environments. When the Flash-ECG implemented in a pilot WebCT course with one virtual cardiologic patient for 42 students in winter 2006, 89% of the students reported the Flash-ECG to function technically well, whereas only 11% reported some delay in image loading when using a home PC. Currently, we have successfully implemented the Flash-ECG to our MySQL-based virtual patients (Virtual Patient Pool VPP) with a more powerful server. Since its introduction in May 2006 students have reported no technical problems with the Flash-ECG Figure 1. The Flash-ECG interface. From a drop menu Limb leads will display I, II, III, aVR, aVL, and aVF Chest leads will display V1-V6 The six-second ECG ruler and four typical QRS patterns of LBBB & RBBB can be selected with a separate drop menu. Figure 2. The transparent 6 s ruler of the Flash-ECG interface. Freeware eLearning Flash-ECG 551