The strengths and challenges characterizing electrophysiology in the digital age, as discussed in the recently published 'The Digital Journey' for Europace's 25th anniversary.

Reading this article allows for an intellectual "journey" through the advancements that digital technology has made in the field of electrophysiology in recent years. To facilitate this exploration, the authors have curated a selection of the most impactful papers published in the Europace journal over the last 25 years, focusing on five major areas of interest: 1) Telemonitoring of Cardiac Implantable Electronic Devices; 2) Digital Devices; 3) Mobile Health Applications; 4) Virtual Clinics; 5) Artificial Intelligence and its Regulatory Aspects.

In discussing each of these subjects, the authors have comprehensively outlined both the strengths and the challenges that characterize them.

In the first section dedicated to telemonitoring of cardiac implantable electronic devices, the authors explain the importance of the development of this tool. They note that it has evolved to a fully automated system to complement in-office follow-up¹ and has gained even more importance during the COVID-19 pandemic². Previous studies have shown a reduction in time to detection of clinically actionable events, prompting earlier intervention with the implementation of remote monitoring (RM) compared to standard in-person follow-up care. Furthermore, RM has been shown to produce a significant reduction of all-cause mortality³. Despite its various proven clinical benefits, the authors caution that RM implementation and uptake have been modest due to multifactorial barriers related to patient factors such as health literacy, preference and access, lack of healthcare infrastructure, and inadequate reimbursement⁴.
In concluding this section, the authors discuss the issue of the increasing volume of RM transmissions, which has reached significant proportions, thereby increasing clinical workloads. They suggest that artificial intelligence could help in addressing this issue.

In the second section dedicated to Digital Devices, the authors elucidate the significant evolution that cardiac rhythm monitoring has experienced over the past 25 years. They detail how technology has advanced from the initial Holter monitors to sophisticated wearable devices such as smartwatches. These modern devices are indeed capable of providing a diverse array of information, including heart rate, as well as physical activity metrics. Furthermore, owing to their capability to perform electrocardiograms, these devices are increasingly being utilized for screening conditions like atrial fibrillation, as evidenced by numerous recent studies^5-6. However, challenges such as the accuracy, reliability, and complexity of data interpretation remain. 

Similar to digital devices, the field of mobile health has also experienced substantial growth in recent years. The advent of smartphones with advanced features has expanded these applications in the field of Electrophysiology. These apps serve various purposes including clinical decision support, treatment adherence, and patient education. They also offer the potential for remote disease management and diagnostic screening, such as for arrhythmias. Despite the wide availability and manifold opportunities, several barriers to their effective use exist, including lack of validation and poor integration with existing healthcare systems.

In the fourth section, the authors explore the idea of "virtual clinics," a topic that is especially important in light of upcoming healthcare challenges. The expected lack of healthcare providers, such as doctors and nurses, combined with a rising number of chronic illnesses, puts significant strain on healthcare systems, particularly in settings with limited resources.
Using the tools mentioned earlier, like smartphone apps and remote monitoring of Cardiac Implantable Electronic Devices, virtual healthcare environments have shown levels of effectiveness, safety, and patient satisfaction that are comparable to traditional, face-to-face consultations^7-9. Initiatives like TELECHECK-AF¹⁰ have gained widespread approval across a variety of healthcare systems. Virtual clinics for the management of anticoagulation have been well established¹¹  and those for post-AF ablation patients show potential¹². However, challenges remain, including the need to focus on patient-specific factors such as digital literacy and individual preferences, as well as the inherent limitations in virtually managing more complex medical conditions.

In the fifth and final section, the Authors address the subject of artificial intelligence (AI). They begin by reminding readers that AI and machine learning (ML) are quickly advancing fields within data science capable of classifying complex data and, in turn, predicting future patterns or risk events. The first AI study published in Europace dates back to 2003, well before its 25th anniversary. Since then, numerous studies have delved into the use of AI for managing arrhythmias like VT/VF and beyond. For instance, AI technologies have made it possible to identify patients with left ventricular dysfunction¹³ or paroxysmal AF using a 12-lead ECGs during sinus rhythm¹⁴. Moreover, Convolutional Neural Networks (CNNs), when applied to ECGs, have been shown to identify echocardiographic left ventricular hypertrophy more accurately than clinicians^15. In the final part, the authors emphasize the importance of prudence in introducing new digital technologies into healthcare settings. Drawing upon a 2019 editorial in Europace by Loring and Piccini, they caution that the application of machine learning in big data should be carefully managed, as artificial intelligence is not immune to biases in study design. Achieving the correct balance between safety and innovation remains an ongoing effort¹⁶, made increasingly complex by the existing regulatory environment, including EU frameworks like the General Data Protection Regulation (GDPR) and the Medical Device Regulation (MDR).