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18 Practical Operating andEducational Solutions
315
Key Recommendations
1. The supporting structure of any successful program should include an operating
solution to store images for quality, education, and credentialing.
2. Practical operating solutions can help create a workow process in programs that
are starting with limited or no resources by keeping the cost low.
3. Once a workow has been established, consistency will help promote the
process.
4. Automatization of process should be a goal to help with compliance of the end
users.
5. Creating a team consistent of IT, PACS administrators, documentation (EMR if
applicable), and revenue can help streamline process, with goals of review and
improve process.
6. Education is an integral part of POC US, so content development and delivery
should be a priority to impart knowledge and use as a tool to improve process.
7. Exploring all resources of your institution, such as current software being used
or LMS systems in place, can help minimize cost and gain support.
References
1. American College of Emergency Physicians, Policy Statement. Ultrasound Guidelines:
Emergency, Point of Care and Clinical Ultrasound Guidelines in Medicine. June 2016.
2. OsiriX Dicom Viewer. www.osirix-viewer.com.
3. Showcase DICOM Image Viewing Software. www.triltech.com.
4. MicroDicom Image viewing Software. www.microdicom.com.
5. I Do Imaging DICOM viewing software. www.idoimaging.com.
6. Picasa. www.picasa.google.com.
7. Flickr. www.ickr.com.
8. Dropbox. www.dropbox.com.
9. Google Drive. www.drive.google.com.
10. Amazon Cloud Drive. www.amazon.com/clouddrive.
11. iCloud. www.icloud.com.
12. Symform. www.symform.com.
13. Sookasa. www.sookasa.com.
14. Ultrasound of the Week Clip Deidentier. www.ultrasoundoftheweek.com/clipdeidentier.
15. Ultrasound of the Week M-mode Creator. www.ultrasoundoftheweek.com/m-mode-ify.
16. Sonocloud. www.sonocloud.org.
17. Kang TL, Berona K, Elkhunovich MA, Medero-Colon R, Seif D, Chilstrom ML, Mailhot
T.Web-based teaching in point-of-care ultrasound: an alternative to the classroom? Adv Med
Educ Pract. 2015;6:171–5.
18. Turner EE, Fox JC, Rosen M, Allen A, Rosen S, Anderson C.Implementation and assessment
of a curriculum for bedside ultrasound training. JUltrasound Med. 2015 May;34(5):823–8.
19. Lewiss RE, Hoffmann B, Beaulieu Y, Phelan MB. Point-of-care ultrasound educa-
tion: the increasing role of simulation and multimedia resources. J Ultrasound Med.
2014;33(1):27–32.
20. American College of Emergency Physicians, Policy Statement. Ultrasound Guidelines:
Emergency, Point of Care and Clinical Ultrasound Guidelines in Medicine. June 2016; 6–7.
316
21. Screenow: http://www.telestream.net/screenow/.
22. Camtasia Screencast: https://www.techsmith.com/camtasia.html.
23. Adobe Authorware: http://www.adobe.com/products/authorware.
24. Articulate: https://articulate.com.
25. Moodle: https://moodle.org.
26. Blackboard: http://www.blackboard.com.
27. Absorb LMS: https://www.absorblms.com.
28. Docebo: https://www.docebo.com.
29. Litmos: http://www.litmos.com.
30. Mindash: https://www.mindash.com.
31. DigitalChalk: https://www.digitalchalk.com.
P.E. Duran-Gehring and A. Tirado-Gonzalez
Chapter 19
Politics ofPoint ofCare Ultrasound
Paul R.Sierzenski
Objectives
• Discuss the political landscape at the departmental, hospital, regional, state and
federal levels.
• Understand and dispel common misconceptions of point-of-care (POC) ultra-
sound politics.
• Highlight major ultrasound milestones, events, policies, and documents affecting
point-of-care ultrasound.
• Understand looming hurdles such as accreditation and value based medicine.
Introduction
What makes politics both exciting and frustrating is that the issue to be negotiated
or resolved represents a topic for which two or more parties are intensely passionate. Politics can be dened as: “activities that relate to inuencing the actions and
policies of a government/or governing body” [1]. In this chapter, we will discuss the
concept of clinician-performed point-of-care ultrasound instead of specialty specic ultrasound, since thinking in this broadest sense helps understand political
challenges and opportunities.
Interestingly, emergency physicians have used, researched, and developed emergency ultrasound for decades, yet many emergency providers still lack access to the
technology. One would think agreement would be fairly simple, especially when
supporting a patient centered approach. Yet we repeatedly see that progress takes
P.R. Sierzenski, MD, MS HQS, FACEP
Acute Care Services, Renown Health, Reno, NV, USA
e-mail: peski71@icloud.com
V. S. Tayal et al. (eds.), Ultrasound Program Management,
https://doi.org/10.1007/978-3-319-63143-1_19
317© Springer International Publishing AG 2018
318
time since much of the opposition and support for clinician-performed ultrasound
are rooted in deep biases and have the propensity to acutely reoccur as might a
chronic relapsing medical condition.
P.R. Sierzenski
Departmental Aspects
There still exist and may always exist individuals in your departments, ofces, or
clinics who are opposed to the use of clinical ultrasound. In fact some of their concerns are likely based on valid points. They will cite issues with work ow, risk
management, competency, cost, and patient experience. We certainly can’t dismiss
these concerns, rather we have to understand them, their motivation, and feel comfortable that we’re able to address them in order to optimize patient care in our
high- risk environment. If we cannot adequately respond to such concerns it is likely
that we do not fully comprehend why ultrasound is of benet at the patient bedside.
This chapter and textbook will strategically address each of these issues, any of
which may be the leverage point for or against the initiation or expansion of a Pointof-care Ultrasound program.
There is a departmental component that will evaporate over time, and that is the
general resistance to technology. It is a generational problem. The status quo is
often comfortable. In a world that is moving to pay for value, from payment for
performance (RVU based), we must be able to address the real concerns of point-ofcare ultrasound critics. The traditional position is that a team is only as strong as its
weakest link. As you develop concepts for a program or its expansion, challenge
yourself with the feedback and views of the individuals most opposed to point-ofcare ultrasound.
Interdepartmental Aspects
There are a number of departments, which the Point-of-care Ultrasound Director
will need to successfully engage including cardiology, medicine, critical care, emergency medicine, and obviously radiology. Some of these specialties will align with
your needs and others might be obstructive. The opportunity exists since early
point-of-care ultrasound adopters are well positioned in this space to leverage your
background, passion, knowledge, and time to gain support such as assisting anesthesiology in training staff for ultrasound guided access, or assisting OBGYN in the
development of a documentation pathway, or aiding trauma in their ACS trauma site
visit through E/FAST exam QA documentation. The assets you bring are
extensive.
An important trend to recognize among our colleagues in Radiology is they
are beginning to understanding the use of this technology from our standpoint.
19 Politics ofPoint ofCare Ultrasound
319
BothEmergency and Radiology Residencies have a mandated ACGME Milestones
for residents to perform “ultrasound.” However the Radiology Residency Milestone
document sites the term “ultrasound” only once [2], and others are likely to follow
in time the Emergency Medicine Residency Milestone document lists “ultrasound”
11 times with details in “Other Diagnostic and Therapeutic Procedures: Goaldirected Focused Ultrasound (Diagnostic/Procedural) (PC12)” and has done so
since 2012 [2], a powerful fact that deserves publicity and duplication in other areas
of practice.
National Organizational Aspects
When is it obvious that an issue in healthcare has reached a signicant level importance? When everyone has a statement, position, or policy about the issue. The following is a prominent list of well-known organizations that have publically
discussed, supported, or raised concern or outright objection to Point-of-care
ultrasound:
AAEM—American Academy of Emergency Medicine
AAFP—American Academy of Family Physicians
ABEM—American Board of Emergency Medicine
ACC—American College of Cardiology
ACOG—American College of Obstetrics and Gynecology
ACOEP—American College of Osteopathic Emergency Physicians
ACEP—American College of Emergency Physicians
ACGME—American College of Graduate Medical Education
ACR—American College of Radiology
ACS—American College of Surgeons
AHRQ—Agency for Healthcare Research and Quality
AIUM—American Institute of Ultrasound in Medicine
AMA—American Medical Association
ARDMS—American Registry of Diagnostic Medical Sonographers
ASE—American Society of Echocardiography
The Blues: Blue Cross and Blue Shield
CMS—Centers for Medicare and Medicaid Services
CQU—Coalition for Quality in Ultrasound
JC—The Joint Commission
MedPac—Medicare Payment Advisory Commission
RRC-EM—Residency review Committee for Emergency Medicine
SAEM—Society for Academic Emergency Medicine
SHM—Society of Hospitalists Medicine
SRU—Society of Radiologists in Ultrasound Congress
NQF—National Quality Forum
320
P.R. Sierzenski
Misconceptions Regarding Point ofCare Ultrasound
There are many misconceptions with Point-of-care ultrasound and here we will focus on
10 most commonly seen ones. Realistically, these are mainly “straw man arguments.”
1. Clinicians are not competent at using ultrasound. This remains a pervasive
misconception at all organizational levels and within hospitals and health sys-
tems. Hospital medical executive boards may not hold a current world view or
realize the rapid integration of clinical ultrasound since 2010, and it is our chal-
lenge and duty to educate them. Substantial evidence exists about training rates,
competency curves for emergency physicians, PAs, nurses and other clinical spe-
cialties’ safe use of ultrasound.
2. Point-of-care ultrasound will increase costs. Arguably this misconception could
be the number one challenge, as this is rapidly becoming the default position after
research disproved concerns regarding competency. There are two points to con-
sider, rst that clinical ultrasound examinations are typically billed as “limited
codes” and thus are only a fractional cost compared to “complete codes” billed by
traditionally imagers. Second, as medicine continues to move away from pay for
volume to pay for value, the lower expense of the limited ultrasound and its real-
time performance can reduce variable costs across the health system. These variable
costs include reducing transportation, stafng (traditional sonographers) and
improved efciency leading to reduction of time to clinical decision-making.
Additionally as a move away from traditional imaging processes can result in repur-
posing of care spaces such dedicated ultrasound rooms.
3. Point-of-care Ultrasound is not best clinical practice. From procedural guid-
ance to diagnosis in pregnancy, shock, soft-tissue, renal colic, biliary colic,
trauma, ocular, thoracic, venous thrombosis point-of-care US is considered a de
facto standard of care [3].
4. Point-of-care Ultrasound is not a residency standard. This is an ACGME/
ABEM Milestone in EM, and mentioned in multiple other specialties in proce-
dures or knowledge competencies (see residency chapter).
5. Point-of-care Ultrasound will increase misdiagnosis/risk. Point-of-care
Ultrasound has been shown to reduce and focus the differential diagnosis of
emergency physicians, especially in the critically ill hypotensive patients.
6. Self-referral issues represent a Stark violation. Studies and documentation
should meet CMS documentation and clinical indication requirements. A proce-
dure by the examining physician is not self-referral during the visit.
7. Point-of-care Ultrasound is unnecessary as other services are available.
Though other consultative services may be available, they are not contemporane-
ous to real-time clinical care. Hypotensive, septic and ultrasound guided proce-
dures alone debunk this myth.
8. Point-of-care Ultrasound decreases physician performance. Point-of-care ultra-
sound actually improves physician decision-making, reduces differential diagnosis,
reduces time to diagnosis, improves patient satisfaction, and improves safety.
9. Point-of-care Ultrasound is a fad. This has been said repeatedly since 1994! At
some point, perhaps after a few decades, things can no longer be just fads.
19 Politics ofPoint ofCare Ultrasound
10. Point-of-care Ultrasound is an extension of the physical exam. Now this is
a politically difcult myth as many have used it to justify gaining Point-of-care
Ultrasound clinically or for medical student training. Yet the fact remains that
ACEP has recognized that ultrasound is a focused imaging service as detailed
in the 2013 ACEP Council passed resolution 33 which states:
Resolution 33 Clinical Ultrasound is a Specic Imaging Modality (as amended).
RESOLVED, That ACEP dene Clinical Ultrasonography as a diagnostic modality;
and be it further.
RESOLVED, That ACEP recognizes that Clinical Ultrasonography goes beyond
clinically important data not obtainable by inspection, palpation, auscultation, or
other components of the physical exam; and be it further.
RESOLVED, That ACEP recognize Clinical Ultrasonography as a unique clinical
modality, distinct from the physical examination, and not an adjunct to or exten-
sion of the physical examination [4].
321
The Contrarian’s Viewpoint
There remains a signicant disconnect between what providers or clinicians in
various specialties do every day when taking care of patients; on nights, on weekends, on holidays, and the challenges and variability of resources that are available
to care for patients. Point-of-care Ultrasound is an attempt by clinicians to advocate for patients to have a consistent standard of care that meets our commitment
to serve the healthcare need of society 24/7/365. It’s a disconnect from the work we
do, we need to do and the current realities of the system, or future system of care
to develop.
Point ofCare Ultrasound Political Backstory
In 1991, the emergency ultrasound shot was heard around the organized medical world.
The next several graphs depict the key public position statements by organizations for
and against Clinician-Performed Ultrasound from the 1990s through 2012. These documents and their impact are too vast to discuss in detail for this chapter. However, they
should be known or accessible to any proponent of point-of-care ultrasound.
Paramount for individuals seeking to initiate a new point-of-care ultrasound program are the following ve documents:
1. The 1999 AMA HR 802-Privileging in Ultrasound Imaging, the resolution from
the house of medicine that unequivocally states that clinicians have the right to
use ultrasound, be trained in ultrasound and develop specialty specic guidelines
and criteria for hospital privileging and credentialing (Fig.19.1).
2. The 2001 (and updated) ACEP Emergency Ultrasound Guidelines.
322
EUS Events: 1990’s
Feb 1999
June 1999
EUS Events: 2000’s
March 2005
P.R. Sierzenski
3. 2001 AHRQ Evidence Report No. 43. Making Healthcare Safer; Ultrasound
Guidance for Central Venous Cannulation.
4. 2010 ACEP/ASE; Focused Cardiac Ultrasound in the Emergency Setting.
5. 2011 AIUM Ofcially Recognizes ACEP Ultrasound Guidelines.
6. SCCM Hospital Credentialing pathway published in 2014 (Figs. 19.2, and 19.3).
ACEP:Use of Ultrasound Imaging by Emergency Physicians
ACR:Standard for performing & Interpreting Diagnostic US Exams
AIUM:Training Guidelines for Physicians Who Evaluate &
interpret Diagnostic Ultrasound Examinations
ACC:Echocardiography in Emergency medicine
CMA:Ultrasound Examinations
AMA:HR802 Privileging US Imaging
1991
1992
1993
Fig. 19.1 EUS Events 1990s
ACOEP: Emergency Department Ultrasound
AMA: H385.934 Reimbursement for Office based Outpatient
ACEP: 2001 Emergency Ultrasound Guidelines
AHRQ: Evidence Report NO 43. Making Health Care safer
April 2000
June 2000
July 2001
June 2001
Fig. 19.2 EUS Events 2000s
December 1999
Ultrasound Imaging (updated in)
Ultrasound Guidance for Central Vein Catheterization
CQU: Ultrasound Credentialing & Accreditation
MedPac: Recommendations
on Imaging Services
ACEP: Imaging
Compendium Criteria
Sept 2004
April 2006
March 2012
EUS Events: 2010’s
19 Politics ofPoint ofCare Ultrasound
ACEP/ASE: Focused Cardiac Ultrasound in the Emergent Setting
SDMS: Point-of-Care Ultrasound Position Statement
ACEP: Emergency Ultrasound Standard Reporting Guidelines
AIUM: Recognizes ACEP EUS Guidelines
CDC: Guidelines for prevention of CVC infections
Oct 2011
Sept 2010
Sept 2011
Fig. 19.3 EUS Events 2010s
Nov 2011
April 2011
Recent Developments toKnow
323
ACGME: Pulm/CC training Guidelines
ASA: CVC Guidelines
April 2011
Late in 2012, the American College of Radiology in its ACR Appropriateness
Criteria ® rated highly the Focused Assessment in Sonography for Trauma
(E/FAST) exam. The FAST received an eight out of ten rating, ve points higher
than a CT abdomen and pelvis with or without contrast, which scored a 3 as noted
below (Fig.19.4):
In 2013, AMA House Resolution 507–2013 titled; Diagnostic Ultrasound
Utilization and Education supports the integration and use of ultrasound throughout
the continuum of medical education. At the time of publication it is estimated that
over 40 medicals schools include clinician-performed ultrasound within their 4-year
medical school curriculum, with a constant increase in this number.
Reimbursement forPOC Ultrasound
Fair payment for fair work is reasonable. During the early phases of negotiation,
raising issues of payment for point-of-care ultrasound can be a “third rail” risking
turmoil and frustration. This is not to say it should be taken off the table, as that is
potentially problematic. As noted by the AMA, it is unethical for other specialties
and stakeholders to suggest such a concept. Other chapters will discuss the detail,
324
Clinical Condition:
Varlant 1:
Date of origin: 1996
Last review date: 2012
P.R. Sierzenski
American College of Radiology
ACR Appropriateness Criteria
“
Blunt Ab-dominal Trauma
Unstable patient.
Radiologle Procedure Raing Comments RRL*
To evaluate for fracture,
pneumomediastinum, and abnormal air
collection or gas collections, patient
condition permitting. Chest radiograph,
X-ray chest:
US chest abdomen and pelvis (FAST
scan)
X-ray abdomen and pelvis (KUB)
Arteriography with possible embolization
abdomen and pelvis
CT abdomen and pelvis without contrast
CT abdomen and pelvis with contrast3
8
KUB, and Fast scan are complementary
examinations. All are commonl
performed in this setting, patient condition
permitting.
Rapid assessment of free fluid, patient
condition permitting. Chest radiograph,
KUB, and FAST scan are complementary
8
examinations. All are commonly
performed in this setting. patient condition
permitting.
To evaluate for fracture, free
intraperitoneal air or abnormal fluid or gas
collections. Chest radiograph, KUB, and
8
FAST scan are complementary
examinations. All are commonly
performed in this setting.patient condition
permitting.
Not appropriate as initial imaging
modality but may become more
appropriate if additional clinical
5 Varies
information or imaging suggests
possibility of active hemorrhage.
Not appropriate for critically unstable
patients. Appropriateness rating may
increase if clinical condition of patient
improves and becomes hemodynamically
3
stable. Would only consider in setting of
prior serve contrast reaction or renal
failure.
Not appropriate for critically unstable
patients. Appropriateness rating may
increase if clinical condition of patient
improves and becomes hemodynamically
stable.
Fig. 19.4 ACR appropriate criteria—Blunt Abdominal Trauma
regulations and options related to billing and payment for point-of-care ultrasound.
However one aspect is clear, a quality program developed with the patient as the
focus is critical. Once reimbursement is raised as a topic, the altruistic high-ground
can be lost, it is best to focus on the patient and move to discuss the support of the
program and the development of a self sustaining point-of-care ultrasound
program.
Of course clinicians are right to obtain fair pay for their work effort, however that
can take many forms (fee-for service, fair-market-value at rate payments for services, etc.) and with a healthcare system in transition, over-xation on reimbursement can backre.