Saroj Misra, DO

 Each month, physician reviewers will evaluate a particular app or category of apps that provide some functionality for medical practices and/or patients.

 is designed to increase a physician’s ability to understand auscultated sounds by way of providing visual waveforms for both cardiac and pulmonary sounds. I found the stethoscope to be an intriguing approach to taking traditional data and making it more useful for both point-of-care utilization and teaching purposes.

The Core quickly became my default stethoscope because of its audio and digital amplification quality as well as its ability to record waveforms. It wasn’t perfect-its main problem is a heavy digital head that kept falling off the tubing-but it was a promising start.

Now, early adopter physicians around the country are getting their hands on the company’s latest model, the 

. As its name suggests, the Duo focuses on two things in addition to traditional auscultation: the ability to record audio waveforms of cardiopulmonary sounds AND capture electrical activity in the form of a single-lead EKG. This is amazing and adds a whole new dimension to the traditional art of auscultation.

Jason Bellet, one of Eko Health’s co-founders and current vice president of provider solutions, told me they started the company back in 2013 at University of California, Berkeley because they wanted to develop a tool that could augment cardiopulmonary assessment. They spent a long time working with established cardiologists to understand what was needed.

Ultimately, they decided modifying the stethoscope was an ideal way to bridge the gap between traditional auscultation and data analysis and evaluation. They wanted to ensure that their device could be used in a fully digital fashion complete with excellent fidelity and also capture data in an interactive way to make the findings actionable. With the Duo, the company is one step closer to its vision of a product that can gather, analyze, and interpret traditional physical findings.

The Duo brings together multiple pieces of information. There is traditional auscultation of the heart and lungs combined with audio waveforms of the sounds, a phonocardiogram, and a single-lead EKG that, depending on chest placement, can act as different leads from a traditional 12-lead EKG.

The Duo will definitely cause providers to do a double take. At first glance, the Duo looks like a stethoscope earpiece/tube combo connected to a long silver box as opposed to the traditional bell/diaphragm combo. The box is where all the magic is housed, as it connects to stainless steel leads as well as the audio transducer. The Duo’s tubing actually screws into the box. This is a godsend modification for anyone who encountered the frustration of the original Core’s transducer, which constantly slid off the tubing because of its weight.

In practice, the Duo can fairly easily be used as a traditional stethoscope. There are some issues when using it for cardiac auscultation with women because of anatomic considerations, but a bit of careful maneuvering makes the process easier. Excessive body hair also makes it difficult to get an accurate EKG, but this was not a consistent issue. The tubing connecting the earpieces to the transducer is a little short, but any longer and the transducer’s oblong shape would probably make it awkward to carry. Last, the tubing cannot be swapped for another tube, such as with the Core, because of the proprietary connection to the transducer.

What is very convenient is that the entire transducer can be separated from the earpieces and used separately if you have a smartphone or tablet. Because the transducer houses a Bluetooth unit, it can send all data, both audio and tracings, to the device. Furthermore, it can be used in real time through your device’s speakers or attached headphones. It is actually feasible to use the transducer the majority of the time without the earpiece, as the transducer is slim and pocketable.

Pros: Ability to do a more thorough heart evaluation and store/send data as needed; portable and solidly built


					Cons: Shorter tube, some difficulty maneuvering the transducer and some challenges with body hair for EKG capture; cost is at high-end of the stethoscope spectrum

All of this information is presented via the Eko app, available for both iOS and Android. The app is a powerful tool that allows you to make several adjustments to the device for listening purposes, including bell or diaphragm frequencies and multiple listening positions for various organs. In addition, the app gives you the ability to play back, store, and transmit both sounds and tracings in a HIPAA compliant fashion. The app itself can store recordings for multiple patients and uses additional security in the form of a passcode or Touch ID on an iOS device to protect patients’ information.

I believe my father, a cardiologist, would have appreciated the ability to take recordings at the bedside and transmit them remotely to others. Bellet says Eko Health is working with EHR platforms to make data integration easy.

Eko Health also offers a premium telemedicine service for $40 a month. This allows organizations or individuals to livestream cardiac sounds to a provider (Bellet described it as “Skype for heart and lung sounds”). The company reports they have partnered with a number of institutions and health systems that are using this feature to allow staff to remotely stream data to physicians not at the bedside, including Children’s Health in Colorado and Spectrum Health in Michigan.

In my first review, I said the Core was replacing my traditional stethoscope because of its added dimensions of utility. I’m pleased to say that the Duo is now replacing my Core. In actuality, you don’t need both. Depending on your need, either one will suffice.

They seem designed for two different markets, and the pricing reflects this. The Core runs $199-$299, depending on which model you choose. The Duo is currently not available to the general public but has a manufacturer’s suggested retail price of $349. Bellet says the Duo will soon hit the market. In the meantime, interested physicians can sign up on the company’s website to be notified when it’s available.

For many physicians, the Core will fit the bill. It provides great audio functionality, analog capability, and the ability to record heart and lung sounds. The Duo ups the ante by including a single-lead EKG functionality. For me, the Duo represents the cutting edge of bedside technology and the possibility of real telemedicine functionality. It is now my default stethoscope for everyday use.

Saroj Misra, DO is a board-certified osteopathic family physician who has served as program director of the family medicine residency at St. John Health System in Warren, Mich.

Articles

This stethoscope and accompanying app help healthcare providers hear and see the heart in a whole new light.

App review: Eko Duo Stethoscope

Each month, physician reviewers will evaluate

a particular app or category of apps that provide some functionality for medical practices and/or patients. 

These days, anybody can attempt to determine their medical conditions. However, most individuals who aren’t physicians don’t have good ideas about how to diagnose the problem(s) or symptom(s) they are experiencing. The advent of computer software, the ability to parse large volumes of data, and the power of algorithms have made it possible to take a statistical and scientific approach to differential diagnosis. Whether this is an accurate and/or usable approach is an entirely different question.

Health Check – Symptom Checker Review was designed with a plug and play interface to allow users to determine a differential diagnosis by inputting the known symptoms. The app is clearly designed for non-medical people, even going so far as to put up obligatory warnings about using it and seeking professional help if needed. Company and lead design Cezar Popescu said in an interview with 

 that the goal was to create a desktop-based application that helped patients to check symptoms. His company, 

, focuses on developing desktop-based software to do just that on the Mac OS X platform.

The app costs $4.99 from the Apple App Store and, as of this writing, was one of the top featured apps in the medical category. However, because it is relatively new, the app had only six ratings, though most are good. The app presents a fairly simple interface for users who choose an organ-graphically represented on a human outline-then use a drop-down list to identify their symptoms. The right half of the screen has a slider for users to indicate the intensity of each symptom. Users may add multiple symptoms for a single case and separately rate the symptom’s intensity. The intensity scale uses phrases such as low, moderate, and extremely high that, while descriptive, aren’t very specific.

The app becomes very interesting after users click on the “Find Diagnosis” button. At that point, the application spits back a number of potential disease processes along with the probability, expressed as a percentage, for each. Each disease process has an info button that provides additional information about the condition including a layperson description, gravity of the situation, incidence per 1,000 people, and commonly associated symptoms. Users can create profiles to save and track their symptoms over time.

Three physicians, from the Romanian town where the company is located, developed the database for the disease lists and percentages based on patient volumes and complaints. Lead physician Camelia Lacatusu is the mother of the software developer, and Popescu said she has more than 30 years of experience in internal medicine. The other two physicians are identified as a surgeon and neurologist. The data was cross-checked against online databases, although the databases were not specified. Lastly, the company states that algorithmic stability was assessed at each stage of the app’s development, although the process was not identified.

The real question is: How does this application measure up against other free online applications with a similar or identical functionality, such as 

I compared the apps using three relatively simple findings: blood in urine, lower abdominal pain, and frequency of urination. I entered them into the symptom checkers to see if they returned diagnoses of kidney stones and urinary tract infections (UTI). All three came to the same conclusions, but Health Check and WebMD were quicker and much more accurate. The Mayo Clinic’s Symptom Checker couldn’t get the right diagnoses from lower abdominal pain and took me down a very different path but corrected when I started with the symptom of hematuria. Health Check was the only one to give specific percentage probabilities, while WebMD used ratings of moderate and fair for matches.

Recommend to patients?: For basic evaluation only; not comprehensive or accurate enough for routine use.

The challenge here is that none of the tools returned kidney stones or UTI as the first or most likely diagnoses, which is what my random sample of residents and physicians consistently did. This simple test demonstrates that such tools are not likely to be effective as replacements for clinical evaluation. To be fair, all of the tools suggest that their use is limited and should prompt further evaluation by a qualified physician.

Keeping these disclaimers in mind, Health Check does an OK job of filling that need. The challenge will be to see if the company continues to update it. Popescu said they are planning to add 50-100 disease states over the next six months based on popularity of the app and broaden the symptom list.

The cost ($4.99), though minor, is surprising given the newness of the app and similar free tools on the market such as that offered by WebMD-a well-known resource for self-diagnosis-and the fact that such apps still require clinical evaluation. It is difficult to foretell if such a product has a public market, but it will be interesting to watch how patients choose to use such tools moving forward.

An app for nonphysicians to plug in their symptoms to figure out what’s ailing them.

App review: Health Check – Symptom Checker Review

These days, being a physician is tough due to the ever-increasing and ever-changing number of guidelines that seem to come out on an almost weekly basis. Having an understanding of critical guidelines helps ensure we provide the best and most current recommendations about the many conditions patients come to us with.

As one might expect, there are literally hundreds of such apps out there (not including the massive number of websites one can review). Today, we highlight three that are of significance to the primary-care specialties.

ASCCP Cervical Screening Guideline App (ASCCP)


Guidelines for screening of women for cervical cancer and subsequent management protocols have changed dramatically and multiple times in the last 12 years. With the advent of better HPV testing and review of longitudinal data, physicians are able to make better decisions about how to approach screening and pathologic findings. But the amount of information and options are dizzying - unless you download the ASCCP app.

Designed to be used quickly, the application has four buttons at the bottom of its main page. Clicking on these buttons takes you to screening, management, algorithms, and definitions. One can quickly type in data about a particular patient (or their results) and come up with ASCCP strategies for clinical approach. The number of algorithms provided covers almost every possible situation (including specific patient types, such as pregnancy). The app is clean, simple and quick and I find myself using it on a daily basis. While the $9.99 cost seems prohibitive (and, indeed, there are other apps that do the job for free - just not as comprehensively), the fact that I use this almost daily in my practice more than justifies the expense. I recommend this for anyone who performs or manages cervical cancer screening.

USPSTF Preventative Services Database App (AHRQ ePSS)


The USPSTF (a division of AHRQ) has created one of the most extensive and data-driven list of screening guidelines for patients based on demographic data (age, sex, sexual activity, pregnancy and tobacco use). If you’ve ever wondered exactly WHAT your patients need to be screened for (and what is most likely to increase their morbidity or mortality in a particular age group), this app is for you. Starting with simple demographic data, the app will spit out a laundry-list of recommended screening tests along with a ‘Strength of Recommendation.'

Clicking on a screening will provide further information, including risk factors, rationale and tools related to the recommended screening protocol. Guidelines can be bookmarked to a favorites list as well. Like the ASCCP app mentioned above, the interface is quick and simple. If there is any issue I have with the program, it is that it might be TOO comprehensive. Adding my data yielded at 41 recommendations ranging from “Recommended’ to ‘Uncertain.’ Despite this, I cannot emphasize the value of this program for providing preventative care that is evidenced-based. The low, low cost of ‘Free’ is just icing on this cake.

Guideline Clearing House App (Guideline Central)

What if you could have an app that covers multiple guidelines from multiple sources? This is the aim of an organization known as Guideline Central, whose eponymous app is designed to provide access to the most relevant guidelines for your specialty. Per their description, the company partners with over 35 medical societies and government agencies in the US to provide a comprehensive guideline database that is searchable. The app allows you to tailor guidelines results to your specialty or particular conditions, as well as provide access to useful tools and calculators relevant to the guideline in question. In addition to guideline tools, the app provides access to drug information and quality measures, as well as the ePSS stuff mentioned in the AHRQ app.

As a clearinghouse and ‘one stop’ shop, this app is truly comprehensive - so much so that navigating can be somewhat difficult as you may not know where to start. Playing around with the app increases familiarity quickly and it becomes second nature to find what one needs with time. The app does seem accurate (it did only come up with 40 recommended screenings in it’s ePSS section, as opposed to 41 from the AHRQ app), but can be a little slow to load /retrieve the information. The only catch is that not every guideline is free - while there is a rotating list of free guidelines each month, many are behind a paywall which ranges from as little as $4.50 to $9 for a single guideline. It is true that most of these guidelines can be found for free online - what you are paying for is the convenience of having it available when offline or at point-of-care. The ‘nickel & dime’ approaches has its pros and cons, but overall I found the app more impressive and faster than using the web to find what I needed. Now I just keep looking out for the rotating, free guidelines and download them when available.


All physicians use guidelines daily to make the best judgements for patients - with the apps mentioned above, you’ll be able to do so quicker and more accurately no matter what your specialty of need.

Here are three guideline mobile apps that will help primary-care physicians get their jobs done.

Essential Guideline Apps for the Primary-Care Doc

Quick: You are seeing a 9-year-old patient in your office who was sent to you because of an elevated blood pressure. How do you know what is “normal” for a child this age, let alone what constitutes ‘hypertension’?

Pedi QuickCalc (iOS only) helps physicians  answer this question (and many more) when it comes to pediatric patients in both the ambulatory and inpatient setting. Designed by  W. Kent Bonney, MD, in 2010 (and having received regular updates through 2017), this app was developed to provide a compendium of various calculator-style functions to physicians treating pediatric populations. Currently, the feature list is extensive, but highlights include: BMI calculations, pediatric hypertension calculations and IV fluid rate, and bolus calculations. In addition, the app includes a very good pediatric formulary and dose calculator for rapid bedside answers.

Another interesting approach that this app has taken is to not include native content for things like pediatric immunization schedules

: Extensive calculator list; Quicklink resources; continual updates

: Need WiFi/cellular service to access links; minor aesthetic issues; can’t track measurements

and flu information. While this might seem like an oversight, the app actually includes links to the requisite documents and/or websites (such as the CDC) for this information. In theory, this makes sense, as it decreases the size of the application, while also speeding up use of the application.

That being said, it means if you aren’t on WiFi or in a cellular-data area, these components will be inaccessible. Fortunately, this only limits the application if those are major elements you plan to use regularly. Having links does allow the app to get to some customized elements (for example, a topical steroid table which I found invaluable as a reference). Links need to be checked regularly by the app developer, but (as of this writing) almost all links went to the right documents or websites (the link to the ADHD Evaluation tools linked to an Academy of American Family Physicians article that was by a newer one). Despite some minor shortcomings, the “Quicklink” functionality worked well.

Overall, the interface of the application is highly functional, if not exactly aesthetically pleasing. Entering a weight on the first screen automatically makes the dosage calculator on the second screen provide doses for that particular weight, a very nice touch that speeds along utilization of the app. Additionally, the drug and dose calculator includes a separate category for PALS medications, allowing people in need of just those elements to get to them quickly and uniformly. As I mentioned, some aesthetic choices could be better:the blue background (with gradient coloring and some weird foot symbols in multiple colors) is a bit annoying to the eyes and actually makes some text difficult to read (for example, try putting in a 3-year-old with a SBP of 110 and a DBP of 76). Certain graphic elements (such as the range bar for pediatric BPs) could use a little explanation (and fewer color gradients). Last, there is no way to track measurements for a child or put in multiple measurements for a child to get a plot line. All values entered are “one time only” in nature. This doesn’t make it useless, just not maximally useful for value trending for a particular patient.

After reading the last paragraph, you might think the app is not worth having. In actuality, I believe this app has great value to both the ambulatory and inpatient/ED practitioner. It contains a lot of valuable information and places a priority on speed of use-something any good medical app should do. At $1.99 (iOS only-sorry Android users), this app is a pretty good bargain and the fact that it continues to be updated 8 years after being developed is a strong indicator of the commitment the developer has in it.

I plan to keep using it on a daily basis. Now if they’d only change that background to something easier on the eyes.

Providing lots of valuable information and smart calculator tools, Pedi QuikCalc is a valuable resource for inpatient and outpatient physicians.

App Review: Pedi QuikCalc 

 anniversary last year and has continued to remain one of the most essential and recognizable tools of medical practice, even as much has changed in that same time frame. Despite the central role this device plays in daily medical care, very little has been done to enhance or increase its functionality – until recently.

Excellent recording functionality, ability to share recordings 

lightly bulky, requires intermittent charging

The unit is fairly heavy and will feel much bigger/bulkier to individuals used to a traditional stethoscope model. That being said, the unit itself is fairly simple to operate, possessing a push-through rocker that turns the digital amplification and app connection on or off as well as a button rocker to control the level of amplification. There is also a small port covered by a rubber grommet that allows charging of the device (with a full charge, the Core will work for about a week with regular daily usage, based on my tests). If the unit is off, the stethoscope will still work in what the company refers to as ‘analog mode.’ Once turned on, the unit provides digital amplification and the ability to record auscultated sounds as waveforms to a physician's device.

The Eko Core is the latest in a line of devices designed to use both enhanced technology and medical app functionality to deliver a superior product. At the heart of the system is the Eko Core itself – a typical looking stethoscope with one particular enhancement – the addition of a bulbous digital unit that attaches to the supplied stethoscope tubing. This unit can be purchased separately and added to almost any other stethoscope as well, as it sits in line with the tubing leading to the earpieces and the diaphragm/bell.

It's in the app that the advantages really come through. The app is very effective in displaying and recording waveforms as well as replaying those waveforms through the stethoscope or on your mobile device. The process of recording and playback has improved considerably with the latest version of the app, as has securely accessing the app via Touch ID or 4-digit security PIN. The app also allows the user to integrate recordings into certain EHRs, although the list is currently very slim (only drchrono and Eclinicalworks were listed). Recordings can be stored on Eko's cloud servers and shared via web access with other users.

In practice, I found the Core stethoscope to be easy to use and record with. The digital amplification is almost too sensitive and can sound very shrilly at times, but a physician is able to auscultate heart and lungs sounds as well as (if not better) with practice. The recording feature is very interesting and, as a teaching physician, I find it very useful to be able to play back both heart and lung sounds of patients with specific disease manifestations. Overall, I liked using the Core and plan to replace my regular stethoscope (which was significantly more expensive) with it.

Interestingly, the company is coming out with a new product called the Duo which will function as both a stethoscope and single lead ECG. The app will allow the user to see an electrical lead in real-time paired with an audio waveform recording. The device has not been released yet, but I am intrigued to see how this may enhance a physician's ability to evaluate heart conditions in the ambulatory setting.

The Eko Core and its accompanying app set a new standard for auscultation and I believe that it is a functional combination that is worth the entry price, $199 for the Core attachment or $299 for the Core Attachment and stethoscope combo. I suspect we will see more products come into this market soon and it will be interesting to see how this once-steady medical tool continues to morph in the future.

The Eko app allows physicians to record, playback, and securely share patient heart and lung sounds. Our experts tell you what you need to know.

App Review: Eko Stethoscope

Each month, physician reviewers will evaluate a particular app or category of apps that provide some functionality for medical practices and/or patients.

Editor's note: Portions of this article were reviewed by Victor Abuel, MD.

Any practicing physician will tell you that one of the hardest things to do is maintain current knowledge in areas of

Free; custom content; simple and easy to use; 120,000 resources; good design

Some content requires paid subscription; minor user interface issues; missing topics

practice specialty. Between seeing patients, managing administrative duties, becoming savvy and competent with EHR systems, and trying to find the mythical 'work-life balance' ratio, updating our medical knowledge base sometimes gets shoved to the side.

There are numerous options to help us continually update our knowledge, but most require spending hundreds, if not thousands, of dollars and finding the time to read extensive articles to find critical information that is needed for the everyday practice. Meducation is an app for both iOS and Android platforms that aims to help reduce the time it takes to gain new knowledge while keeping costs to a minimum. Does it succeed in this lofty goal? Sort of.

Meducation was founded in 2008 by two medical students, Alistair Buck and Jeremy Walker, with a goal 'to bring medical professionals and their knowledge together into one digital space to improve the quality of medical education for everyone.' Over the last nine years, the site has managed to have over 160,000 subscribers utilizing and crowd sourcing over 120,000 medical resources in various medical categories. It should be noted that only a fraction of the resources are native to Meducation, with the large majority of them being housed on other sites around the web with Meducation providing a link. The website was redesigned in 2015, coinciding with the release of their app which functions as a portal to the website.

You might ask, why use this app when there are other resources that are more comprehensive? The simple answer is that this app (unlike others) is free and user-curated. What this means is that the content is controlled by users. Anyone with an account can upload a topic, article, or document and the community can up-vote or comment on the items users provide. The more up-votes, the higher in that list the item goes (making it easier to find by others).

In theory, this process should create high-yield content and prioritize it in searches. The user can also create personalized, custom ‘boards’ where they store content they find from others, allowing a degree of flexibility to further personalize what they look at and keep.

The app's interface is simple and easy to use – each tab is self-explanatory. Here and there, some minor user interface issues do crop up (it took me a while to realize I had to refresh by swiping down on my custom boards to see what I had added to them), but the overall interface design works.

A more significant issue is that non-hosted content is more difficult to access. Found a BMJ article for folic acid guidelines? Great, but when you click on it, you only get the abstract and the rest requires a BMJ subscription. Basically, if the content isn't free on the web, it won't be free on Meducation. With this in mind, it's better to think of this design as one that helps you to find specific answers, rather than acting as a compendium.

Another thing to recognize is that the site is heavily trafficked by students. This means many items listed may pertain more to trainees than to a practicing physician. Comments from other users  aren't always helpful and some are clearly just advertising spammers, indicating a little bit better curation of the messages needs to occur (the Meducation website lists an extensive number of section moderators; many are students or residents who may not have time to actively curate these sections regularly).

Some topics aren't represented at all; despite this, I was pleasantly surprised at what I could find with a little searching through the app. It should be noted that the app is simply a portal – everything the app can do can be done via a remote and the website.

I am always looking for ways to read in a 'quick hit' style to ensure that I am always updating my knowledge. While Meducation isn't perfect (not enough content and some user interface issues), it has a visual and aesthetic sensibility that I appreciate. I think if more people actively contributed, Meducation would improve its utility. For now, I'll keep using Meducation here and there.

Despite minor user interface issues, Meducation provides a free method for physicians to continually update their clinical knowledge. 