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6. Expert Round Table on Ultrasound in ICU.International expert statement on training stan-
dards for critical care ultrasonography. Intensive Care Med. 2011;37(7):1077–83. doi:10.1007/
s00134-011-2246-9; 10.1007/s00134-011-2246-9.
7. Expert Round Table on Echocardiography in ICU.International consensus statement on training
standards for advanced critical care echocardiography. Intensive Care Med. 2014;40(5):654–
66. doi:10.1007/s00134-014-3228-5.
8. Fagley RE, Haney MF, Beraud AS, et al. Critical care basic ultrasound learning goals for
American anesthesiology critical care trainees: recommendations from an expert group.
Anesth Analg. 2015;120(5):1041–53. doi:10.1213/ANE.0000000000000652.
9. Pustavoitau A, Blaivas M, Brown SM, etal. Recommendations for Achieving and Maintaining
Competence and Credentialing in Critical Care Ultrasound with Focused Cardiac Ultrasound
and Advanced Critical Care Echocardiography. http://journals.lww.com/ccmjournal/
Documents/Critical%20Care%20Ultrasound.pdf. Accessed 15 Feb 2015.
10. American College of Emergency Physicians. Emergency ultrasound guidelines. Ann
Emerg Med. 2009;53(4):550–70. doi:10.1016/j.annemergmed.2008.12.013; 10.1016/j.
annemergmed.2008.12.013.
11. Cahalan MK, Abel M, Goldman M, etal. American Society of Echocardiography and Society
of Cardiovascular Anesthesiologists task force guidelines for training in perioperative echocardiography. Anesth Analg. 2002;94(6):1384–8.
A. Pustavoitau and E. Su
Chapter 28
Primary Care
ApostololosP.Dallas
Objectives
• Introduce the unique challenges in implementing a primary care ofce-based
ultrasound program
• Review physician educational needs required to establish a program
• Promote a pattern of education that produces a gradual acceptance of primary
care US
• Suggest a method for computing return-on-investment for US machine purchases
• Discuss barriers and pitfalls in managing a primary care program
Introduction
While clinical ultrasonography, variously termed bedside ultrasonography, handheld ultrasonography, portable ultrasonography, and point-of-care ultrasonography,
has found many clinical uses and early acceptance as a valuable tool in emergency
medicine, critical care, anesthesia, surgery, obstetrics, and gynecology, the specialties of internal medicine and family medicine, in general, have only recently begun
to utilize this tool. Hospital use of point-of-care ultrasonography is quickly gaining
traction. However, clinical ultrasonography in the primary care ofce setting, with
its unique challenges, has yet to attain common let alone, generalized use. Literature
supporting use of ultrasound in the primary care ofce setting is scarce and
A.P. Dallas, MD, FACP, CHCP
Department of Internal Medicine, Virginia Tech Carilion School of Medicine and Research
Institute, Roanoke, VA, USA
e-mail: apdallas@carilionclinic.org
V. S. Tayal et al. (eds.), Ultrasound Program Management,
https://doi.org/10.1007/978-3-319-63143-1_28
439© Springer International Publishing AG 2018
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A.P. Dallas
concerns about appropriate use remain. In this chapter, we will describe experiences
at a medical school afliated internal medicine ofce-based practice as an example
and perhaps a model for developing, maintaining, and managing a clinical ultrasound program in the primary care ofce setting.
Needs Assessment
Since the material in this management book is not easily researched, found in textbooks or referenced, practical experience of primary care US, gained over years of
championing outpatient US in the primary care setting will be shared in this
chapter.
The outpatient physician–patient interaction is often one that contains a good
deal of uncertainty. Diagnoses and therapeutic decisions surrounding those diagnoses are often arrived over a period of several visits, labs and imaging ordered
sequentially and not concurrently as in the hospital medicine. An ambulatory
clinic- based physician may need to be comfortable with diagnostic uncertainty
from visit to visit, prior to diagnostic certainty, if that actually ever happens. So the
advent of point-of-care ultrasound can buttress physician decisions. Just as in inpatient settings where the use of ultrasound can change physician decisions, pilot
studies have shown the clinical impact of ultrasound in the ambulatory setting can
be signicant. In one study, medical decisions were reinforced in 76% of patients
and changed in 40% of patient encounters based on the use of ultrasound devices
[1]. While this study was conducted in 2006, over a decade has elapsed and primary
care has still lagged behind in US usage. Noncardiac point-of-care ultrasound by
nonradiologist physicians is not widespread in primary care. In one study evaluating Medicare Part B Physician Supplier Procedure Master les, in 2009 alone,
utilization rates of 425 Medicare noncardiac ultrasound examinations per 1000
beneciaries showed that only 11% were performed by primary care physicians
[2]. From 2004 to 2009, there was relatively little growth in utilization rates among
primary care physicians. A limitation of the study was that it could not account for
the possible ultrasound use in informal, non-billed manners. While the American
Medical Association has declared that each medical specialty should dene its own
requirement in training in ultrasound [3] and other national organizations, emergency medicine for instance, have promulgated guidelines for US training and use,
internal medicine and family medicine organizations have remained silent in this
regard. The members of these organizations have voiced their desire to be taught.
In 2011, the American College of Physicians (ACP) Clinical Skills committee
reviewed feedback from participants in the previous national meeting. Five out of
the top 11 most requested topics for educational needs were ultrasound based,
echocardiography, abdominal ultrasound, vascular ultrasound, etc. The ACP has
responded by offering more ultrasound education at both national and state
meetings.
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Other ambulatory setting practices have been evaluated with respect to US attitudes and utilization. Geriatricians in South Carolina were surveyed to determine
their willingness to adopt the technology and willingness to educate physicians and
medical students and to identify hurdles for implementation in the clinical and
educational environment [4]. Most physicians (92.8%) had heard of bedside portable US and 21.4% had previous formal training. Only one out of 18 physicians felt
comfortable using the machine and none felt ready to instruct other medical staff or
students. Most of the participating group (71–85%) expressed an interest in learning
this new skill. Sports medicine physicians are recognizing the utility of ultrasound
for their specialty beyond the musculoskeletal system and are advocating expansion
of its use in the athlete to diagnose pulmonary, cardiac, solid organ, intra- abdominal,
and eye injuries [5]. Limited abdominal ultrasound has been used to follow splenomegaly in athletes with mononucleosis and to determine regression of splenomegaly prior to returning to competition [6].
In the family practice setting, a group of general practitioners were able to perform assessments of left ventricular function that were comparable to cardiologist
examinations after only minimal training [7]. Another study, looking at rural family
physicians, showed that abdominal aortic aneurysm screening can be safely performed in the ofce [8]. This screening test can be completed with the time constraints of a busy family practice ofce visit, with a mean time to screen of
212seconds (95% CI 194–230). Military family physicians in the clinic setting,
inpatient wards and potentially military- deployed settings found pocket-sized
devices easy to use, valuable in discerning a diagnosis and were not prohibitively
time consuming [9]. In fact, although not measured, physicians felt it actually
decreased the overall time required to make a diagnosis. In addition, patients were
perceived by participants to have been satised with the use of the device.
Practical Considerations
The author’s experience, in a comprehensive hospital and outpatient system comprising over 80 outpatient practices and 8 hospitals, the largest, an 826 bed tertiary
care center in Southwest Virginia, may be illustrative. At Virginia Tech Carilion
School of Medicine (VTC), a recent expansion in clinical departments, residency
and fellowship educational programs and an increase in patient demand led to novel
approaches in delivering care and teaching learners. In this setting of educational
and clinical growth, the Internal Medicine outpatient department served a vital role
in educating students, internal medicine residents, and physician colleagues in continuing medical education activities.
In 2006, Carilion Clinic Continuing Medical Education (CME) began offering
some of the rst courses in portable US for critical care. Because of their signicant
expertise, the faculty teaching in these local courses were invited to plan and teach
courses at national critical care conferences. Since one of the co-chairs of these
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local conferences is an internal medicine physician, the natural progression was to
develop and offer conferences to address the US needs of hospitalists and eventually
primary care doctors. Since their inception, over 700 clinicians have received CME
training in portable ultrasonography.
To complement their education, starting in 2010 the rst year medical students
began a 4 year longitudinal US curriculum. In 2014 this curriculum included
US-guided procedure didactics and model-based hands-on experience. The CME
US offerings as well as the students’ experience with US lead to resident interest
and in 2011, the Internal Medicine Residency program began requiring internal
medicine interns to attend a 24hour US Boot Camp. This camp involved the standard physics, knobs, echo, abdomen, and vascular US instruction as well as
US-guided procedure training. In addition to this Camp experience, lectures and
hands-on US sessions were conducted throughout the year on musculoskeletal,
small parts, sinuses, lymph nodes, and other lumps and bumps.
Our internal medicine clinic’s use of ultrasound began in the above environment
and seemed to be a natural organic growth of US from the inpatient to the outpatient
setting. Some experiences became lessons that were key in establishing and managing this program.
Early accepters of disruptive technology often nd challenges others may not
face. Our earliest efforts to incorporate US in clinical ambulatory medicine met with
skepticism. Some physicians reported, in CME evaluations, that US was exciting
but doubted its widespread application. Others recognized the need to learn it, as
students and residents would be trained beyond the supervisor’s ability to supervise
or teach the learners. The following lessons were learned:
1. A physician champion must be identied. This should be an internist with either
expertise in US or a desire to learn US.The physician champion would be the
communicator of all issues dealing with US acting as a bridge between the clinicians, administrators, and other learners. This person should be prepared to meet
resistance when advocating for US in the primary care setting. While we have
several US machines in our internal medicine clinics, other family medicine clinics have had more difcult times convincing administration that these machines
were necessary and this despite disseminating literature touting US in the ambulatory setting. The physician champion should have a ready supply of references to
support US.Using some of the ones in this book could prove fruitful. An “elevator
talk,” a standard two minute, 6 sentence explanation of the utility of US, should
be available to the champion. This talk can serve as an enthusiasm- generating
micro-educational interlude that can be delivered even as an elevator is traveling
between oors. Physicians have precious little time and to be able to expose them
to some new information quickly is welcomed and much appreciated.
2. The physician champion must then enlist the support of a champion in hospital
administration. Mutual understanding of clinical issues (patient care, physician
workload, etc.) and administrative issues (budgetary constraints, stafng concerns,
etc.) should guide this relationship. It is helpful that the administrator have some
clinical background such as nursing for instance. Often, the reason our CME
28 Primary Care
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attendees expressed their inability to learn and practice US was not being able to
convince an administrator to purchase an US machine. This is the basis for including a lecture entitled, “Selling the machine to your administrator” in our CME US
conferences. We designate this lecture to be delivered by an administrator champion. Buy-in by this administrator to deliver the talk usually signies acceptance
of US as a key modality in any particular setting, hospital or ambulatory.
Key elements to share with administration include return-on-investment, hospital admissions saved, and patient outcomes. While robust data on reimbursement is limited in the ambulatory setting, there is information from other settings.
Implementing a novel point-of-care ultrasound billing and reimbursement program in an emergency department resulted in a 45% increase in faculty participation in billing for patient exams [10]. The number of ultrasound billable
examinations increased 5.1-fold and net prots realized by the ED ultrasound
program was approximately $350,000in one year. In another study, cost modeling for handheld US (HHU) vs physical examination in patients referred for
transthoracic echocardiography revealed that HHU cost $644.43 vs %707.44 for
physical examination when considering all the downstream testing and overall
costs comparing the two [11]. In another study, evaluating bedside ultrasound
and community- based paracentesis in a palliative care service, half of the scans
being performed at home, resulted in less time spent at the local hospital while
not affecting complication rates [12]. And lastly, patient outcomes can be
improved in the outpatient setting with US use. Ultrasound guidance for diagnosis and treatment of shoulder impingement resulted in better outcomes in shoulder function, physician global assessment, and visual analog pain scores [13].
A return-on-investment calculation would include cost of machine and accessories compared against number of diagnostic and US-assisted procedures done.
One should gure out the reimbursement per US use, tabulate this over a time
period, and calculate when the machine will have paid for itself. The clinic needs
to be careful as reimbursement guidelines are constantly changing and several
carriers are now requiring extra training, certication, and/or accreditation in
order to reimburse for limited US in the clinic environment.
3. With the initiation and supervision of the physician champion and with input
from the ambulatory physicians in the clinic, a broad US curriculum should be
established. Initially this should include topics that will drive a simple message
about the utility of US in the primary care setting. Our initial lectures, entitled
“Ultrasound: what you can do in your ofce on Monday” included topics like
carpal tunnel syndrome. A simple US measuring technique can be just as accurate at dening carpal tunnel syndrome as expensive referral for advanced testing
with nerve conduction velocities [14, 15]. In-ofce diagnosis of temporal arteritis
always interests the general internist and the data is so compelling. The nding
of a bilateral halo sign from edema around the temporal artery has a specicity of
100% when compared to temporal artery biopsy [15]. Other topics that challenge
physicians to rethink how they might use ultrasound in the clinical setting include
differentiating Baker’s cyst from deep venous thrombosis, treating meralgia paresthetica, diagnosis sinusitis, evaluating the eye and the temporal mandibular
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joint, performing US-guided arthrocentesis and injections. These are common
conditions encountered by clinicians and to dene how US helps in caring for
patients with these diagnoses may spark interest in other US applications.
The next series of lectures and hands-on centered around musculoskeletal
US, lymph nodes, and lumps and bumps. While in the inpatient setting, cardiac,
abdominal, and vascular US may be more helpful, musculoskeletal complaints in
the outpatient setting are more common and drive US [16, 17]. One case that I
often share when discussing lymph node evaluation was of a 75-year-old gentleman with new axillary nodes of several weeks duration. An ultrasound in the
clinic on his initial visit revealed images consistent with metastatic disease. He
had a biopsy that afternoon and his chemotherapeutic regimen started 3days
later for his lymphoma. He still remains impressed by the rapidity of his diagnosis and treatment.
In order to respect the time constraints clinicians have, the didactic portions
of the education for US for colleagues should be electronically distributed prior
to the hands-on sessions, which we recommend conducting at the least disruptive
times of the day, perhaps during lunch or before clinic starts, whichever the
majority of clinicians prefer. New learners should be given immediate responsibilities to teach others. These task will compel the learner to learn better, as to
teach is to learn twice. Teachers often prepare better, practice more and perhaps,
dreading the appearance of being a novice in front of junior learners, may
become quicker facile practitioners with US.
4. Ultrasound machines should be placed in the most visible areas of the clinic.
Theft concerns aside, the machines should be in a place where nonusers can see
others taking the machines with them into patient encounters, a hallway, perhaps, and not locked up in a special room. This will remind them that their partners are using the machine and may act as an incentive to learn US imaging
themselves, passive peer pressure serving as an effective impetus.
5. The physician champion and supporting physician experts should make themselves available to their partners for quick consultations, to share interesting
cases and images and to act as sounding boards for quality technique and assurance. Two recent cases highlight helpfulness as a bridge to learning. Twice in the
past year, one of our internists was consulted by hand specialists to perform US
evaluations of a damaged transposed ulnar nerve with ulnar neuropathy in one
and a possible exor pollicis longus rupture in another. Both patients had hardware which precluded MRI.In both cases, the US helped dene the damage and
guided the hand surgeons to a much less invasive procedure in one and better
surgical planning in the other. Needless to say, this consultation of a generalist to
help a specialized surgeon was both gratifying to the internist and edifying to
colleagues with which he shared the cases. Another case of being available concerned a retired internist who presented with jaw claudication. An ultrasound
done in the clinic revealed bilateral halo signs with skip areas of involvement
classical for temporal arteritis. The patient was started that day on steroids, felt
great within a week and continues to be impressed with how US has changed
medicine in the few years since his retirement.
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6. Finally, to revisit the issue of reimbursement, the challenges of paying for physician and technical components of US remain. Our experience suggests that billing personal need consistent education and supervision to incorporate systems
for appropriate billing. While this may seem laborious for the physician champion, regular reminders to the billing department, technology services, and the
administrative champion can help to keep this issue from languishing.
Pitfalls
1. Inertia—The rst challenge that must be addressed is the nascent inertia in
changing established practice patterns in physicians. The standard way of practicing becomes ingrained and is difcult to change. Educating physicians with
didactics and hands-on sessions, as discussed already, may be helpful. However,
skills demonstrated to learners will not translate into competency or performance
in those learners unless accompanied by consistent exposure to and practice of
new techniques. Through our US CME courses we’ve noticed physicians returning to take introductory courses and even intermediate courses several times.
When queried about this, the learners reported that since their ofces had not
purchased machines, they had no opportunity to practice and their knowledge
had diminished to the point they needed refresher courses. So, readily available
US machines in the ofce setting will encourage new learners to practice. While
machine availability is necessary, it is not sufcient. Machines can remain
unused if supervision is not available to remind learners of techniques, ranging
from turning the machine on, to image acquisition and optimization, to image
storage and retrieval. Contact between learners and teachers, and access to quick
helpful feedback can address this challenge.
2. Education—in the relatively new expansion of US in the outpatient setting, local
teachers with experience in US and expertise in teaching may be few and far
between. Teaching the teacher programs are key in growing the base of primary
care US teachers. Continued exposure and interest in US will remedy this situation, but will take some time. Although it doesn’t solve all issues, the problem of
availability of local resources can be addressed with internet learning [18].
Learners still value hands-on scanning sessions, small-group formats, and videoclip examples and view them as the most effective methods to learn ultrasound
[19].
3. Time—Physicians report that the time pressure in the outpatient setting limits
their desire to add even a few minutes to patient encounters by utilizing primary
care US.Patient time constraints have limited some opportunities to perform US
as well. This is one of the hardest hurdles to overcome but the utility of US may
trump the extra time cost.
4. Cost—Costs associated with primary care US are not insignicant. In one study,
the top 8 purchasers of compact ultrasound systems did not include primary
care outpatient-based clinics [16]. The costs of machines can be managed
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through return-on-investment calculations and represent relatively hard numbers. The absolute cost of portable US machines has decreased markedly and
several cost less than $10,000 now. The opportunity costs of physician CME
travel to learn US and lost productivity in the learning phase, as a result of
slower patient encounters, slower US machine use, may be more difcult to
quantify. Certainly, e-learning can be less expensive in some regards but still
requires a commitment of time on the physician’s part. Much available e-content is free and even visuomotor and visuospatial skills necessary to create diagnostic images can be as effectively taught via web as in classroom-based
programs [20]. Closely associated with costs of machines and costs of learning
is reimbursement for US use. This is moving target. Payers are changing their
reimbursement requirements and payers in various states have instituted rules
governing reimbursement based on ofce accreditation and physician certication. In addition to documenting in the patient record, storing images for diagnostic and procedural US, checking with local and state policies for
reimbursement is paramount.
5. Quality Assurance—Challenges revolving around competence of physicians
andquality assurance have yet tomake it totheforefront indiscussions.
Key Recommendations
1. Identify a physician champion who will educate colleagues about ultrasound, its
utility, ease of use, ability to help in diagnosis and decision-making and patient
satisfaction.
2. Identify an administrative champion who can coordinate information for returnon- investment calculations and business plan determinations.
3. Dene a longitudinal educational curriculum, rst with easy to learn techniques
involving commonly seen outpatient patient complaints (carpal tunnel, lumps
and bumps) then to more complex skills (musculoskeletal, cardiac US, abdominal US, etc.)
4. Provide educational interludes on a regular basis, during less busy clinic times
such as lunch breaks, to include didactics and hands-on practice sessions.
5. The physician champion should identify other physicians interested in US and
cultivate their enthusiasm to lead and teach.
6. Provide new physician learners responsibilities for teaching students, residents,
and staff quickly in order to motivate them to practice and improve skills.
7. Make US machines readily available so that infrequent users will actually be
reminded of their presence and will easily notice when others are taking machines
in and out of patient encounters.
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8. Enlist the support of billing and reimbursement experts in your institution to
maximize revenue that can support machine use and further purchases.
9. Physician users should make themselves available to colleagues to help demonstrate primary care US utility in their colleagues’ patients.
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