VLM-in-the-Loop: A Plug-In Quality Assurance Module for ECG Digitization Pipelines

ECG digitization could unlock billions of archived clinical records, yet existing methods collapse on real-world images despite strong benchmark numbers. We introduce $\mathbf{\text{VLM-in-the-Loop}}$, a plug-in quality assurance module that wraps any digitization backend with closed-loop VLM feedback via a standardized interface, requiring no modification to the underlying digitizer. The core mechanism is $\mathbf{\text{tool}}\mathbf{\text{grounding}}$: anchoring VLM assessment in quantitative evidence from domain-specific signal analysis tools. In a controlled ablation on 200 records with paired ground truth, tool grounding raises verdict consistency from 71% to 89% and doubles fidelity separation ($\mathrm{\Delta }$PCC 0.03 $\to$ 0.08), with the effect replicating across three VLMs (Claude Opus~4, GPT-4o, Gemini~2.5 Pro), confirming a pattern-level rather than model-specific gain. Deployed across four backends, the module improves every one: 29.4% of borderline leads improved on our pipeline; 41.2% of failed limb leads recovered on ECG-Digitiser; valid leads per image doubled on Open-ECG-Digitizer (2.5 $\to$ 5.8). On 428 real clinical HCM images, the integrated system reaches 98.0% Excellent quality. Both the plug-in architecture and tool-grounding mechanism are domain-parametric, suggesting broader applicability wherever quality criteria are objectively measurable.