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Abstract

Point-of-care ultrasound (POCUS) is a valuable clinical tool used at the patient bedside to rapidly assess a wide variety of symptoms and problems which would otherwise take hours or even days. Though it has become the standard of care in Emergency Medicine and is becoming so in hospital internal medicine, less uptake has been appreciated in the outpatient setting despite reported interest from clinicians practicing there. A number of common barriers have been cited to explain this gap in use, which usually include access to equipment, mentorship, and time. In this review we present a proposed framework for clinicians who have an interest in implementing POCUS in their outpatient practice which we hope can mitigate some of these barriers and provide a more streamlined pathway to their desired goals.

Keywords

practice management primary care point-of-care ultrasound POCUS practice implementation

Background

In recent years POCUS has been demonstrated to have broad clinical utility and in many cases diagnostic accuracy that is similar or exceeding that of other diagnostic tools.^1
-9 Despite widespread interest in Point-of-Care ultrasound (POCUS) and recognition of the benefits it provides to patients and clinicians integrating it into outpatient practices has proven difficult.^1
-8,10
-15 Commonly cited reasons for this challenge include lack of access to equipment and approved education, the need for bedside mentorship, and scanning time during appointments.^10,11,16
-18 Recognizing the barriers encountered to the successful integration of POCUS into the outpatient general internal medicine practice, the authors of this article wish to share our experience gained in diverse clinical settings, including small community-based health systems, larger academic institutions, and internationally. Within this article, we review the current literature on POCUS implementation with the hope that others will find a smoother pathway to success.

Generally, the impetus to develop the infrastructure and support for POCUS in a health system or clinic is driven by clinicians with a background in POCUS who recognize its value in the care of their patients. Unfortunately, knowledge and skill in POCUS and even robust teaching experience are often insufficient for practice integration according to best practices. Though the approach to POCUS integration could be imagined through multiple frameworks, we will share our thoughts on an approach that we found to be effective.^19
-28 The basic steps include defining the problem, identifying stakeholders, assessing needs, evaluation planning, securing organizational support, and sustained engagement. Figure 1 suggests an action item checklist for POCUS program developers, and figure 2 provides one potential example of how a program might evolve over time.

Figure 1.

POCUS implementation checklist.

Figure 2.

POCUS implementation timeline and example case.

Define the Problem

Defining the problems is an essential first step in program success. A clear definition of thereof will inform the remaining steps in program development. In some circumstances the problem(s) will relate directly to patient-centered outcomes, such as a need to improve diagnostic accuracy or the time to diagnosis in select patients. Examples of this might include “reducing the time to diagnosis in patients presenting to the office with undifferentiated cardiopulmonary disease or abdominal symptoms” or “to more accurately identify men whose lower urinary tract symptoms are due to obstruction”. If some clinicians are already using POCUS regularly, the problem may relate more to building infrastructure to improve quality, achieve best practices, or improve sustainability; for example, improving adherence to documentation standards or allowing for billing capabilities. In essence, a single primary problem or group of problems should be identified, but secondary problems can also be listed, which may bolster the case for the intervention.

The problem is best related to something objective, measurable, and of demonstrable benefit to the patient, physician, or clinic. General statements such as “Clinicians do not have adequate access to POCUS” are discouraged since this fails to identify how the project will improve care. Additionally, objective and measurable values will allow clear metrics for program evaluation, which is essential for ongoing improvement. Some systems will be well-positioned to formally study outcomes as a quality improvement study by leveraging the expertise of data scientists and quality experts. In such circumstances, data on time to or accuracy of diagnosis may be reasonable metrics. Others may wish to conduct an informal case review of, for example, patients with undifferentiated dyspnea and report the outcomes of those cases.

Though POCUS has some demonstrated benefits in patient and clinician experience, these benefits can be more difficult to prove and may be insufficient to garner institutional support. Nonetheless, these benefits can be very important to highlight as support in a proposal.^13,29
-32 Patient experience has justifiably become an important metric, which is increasingly tied to reimbursement from third-party payors. Furthermore, healthcare worker burnout is gaining attention as a significant contributor job dissatisfaction, attrition, and organizational costs in employee turnover. Clinicians report the use of POCUS gives them more time in direct contact with patients, is interesting to learn and conduct, and garners positive feedback from trainees, all of which were suggested to reduce concerns for burnout.³³

Identify Stakeholders

A multidisciplinary team is necessary to conduct a thorough needs assessment to minimize unanticipated barriers to success. This will be determined in part by the goals of your POCUS program. Members are likely to include, but are not limited to, clinicians, operational leaders, nursing leaders, information technology, biomedical services, billing and coding, analytics, health information management, research leaders, education leaders, quality, and credentialing.²² Representation is dictated by the intended use of POCUS, regulatory oversight, and institutional factors. For example, if POCUS will be used for educational purposes, educational leadership would naturally need to be involved. If there is no intent to bill for exams performed, billing and coding specialists could be excluded.

It is also recommended that POCUS champions identify and work with an executive sponsor on the project. This could be in the form of a clinician leader, such as a section chairperson or chief medical officer, or an operational leader, such as an operations manager or department director. Ideally this person appreciates the utility of the tool, is effective at working interdepartmentally, and has mature knowledge of institutional policy and procedure. The executive sponsor can be instrumental in helping enlist the involvement of other stakeholders and navigating the multiple processes that must be undertaken to implement the program. Their institutional knowledge of the organizational structure, committee structure, regulatory processes, etc can be crucial to effective program development and implementation.

Assess Needs

As previously indicated, project leaders will perform a needs assessment based on the intended scope of use, available resources, and pre-existent infrastructure (eg, archiving software may be shared with radiology). A comprehensive assessment is often the most challenging step in program development because it requires answering several questions that involve financial considerations, can invoke disputes over the distribution of labor, and frequently requires creative solutions. Depending on institutional size, existing resources, and local practice standards, needs vary substantially between institutions. For example, an institution that cares for many complex and acutely ill patients which has limited availability of cardiology services may benefit greatly from cardiac POCUS. Institutions with widely available echocardiography would have less benefit from this skillset. While assessing needs, it is recommended that the stakeholders not insist on a perfect set of solutions, but rather focus on maximizing benefits and minimizing harm. Not every institution will have the financial resources to secure the best available equipment or software and may not have the operational or information technology (IT) bandwidth to employ sophisticated workflows and technology integration. Nonetheless, ask yourselves if your patients are better served with a POCUS solution that is practical and attainable in your institution.

Early in program development, while working toward system readiness, clinicians may wish to gain some comfort with the use of ultrasound devices and their clinical utility to have a clearer understanding of their program needs. Others may simply wish to gain some experience and skill to ensure POCUS is a good fit for them before embarking on a large project that may prove needless if they do not incorporate it regularly into practice.^13,19 Indeed, many programs have evolved this way by necessity. This practice need not be discouraged while POUCS use gains traction in the primary care practice, though we must take care to ensure we are honest with ourselves and our patients about our level of knowledge and skill. Many users early in the learning phase will use POCUS more as a “shadow” diagnostic tool; continuing to use traditional tools in decision-making while they explore the accuracy and utility of this new technology and gain procedural skills.

Definition of Scope

Though not strictly a need, an important step in assessing needs is to understand what indications POCUS will be used for. This will guide much of the needs assessment. A deeper discussion of POCUS indications in primary care is beyond the scope of this review, but it is worth noting a few considerations here. The list of possible uses for POCUS in primary care is extensive. In the authors’ experience, however, there are certain exams that are very high yield because they are simple to learn and conduct, and answer frequently encountered and important clinical questions. For those who are already broadly skilled in POCUS this will be intuitive. For those who are learning, consider starting with 1 or 2 simple applications and build your skill on those. Excellent examples would include urinary bladder in order to check a post-void residual volume, jugular venous pressure for those patients in whom an intravascular volume assessment is difficult, a knee (or other joint) exam to perform ultrasound guided injections, or hand joints to assess for synovitis.^34
-40

POCUS has been shown to have excellent accuracy in identifying proximal deep venous thrombosis of the proximal lower extremities as well.⁴¹ Clinicians may be uncomfortable with the risk of missing a DVT with their exam, but it is worth noting that POCUS performs approximately as well as full Doppler Ultrasonography in a number of trials summarized in the article by Theophanous, et. al. Furthermore, clinicians probably overestimate the risk of litigation in this situation. In fact, the risk of not using point of care ultrasound when it is available in the Emergency Medicine literature has shown greater risk for litigation than misdiagnosis.

Cardiac POCUS is very difficult to perform well consistently and takes dozens of scans to gain even mediocre competence for many learners. As such, it should be pursued only by those with the time, energy, and passion to learn it well. We would advocate for becoming very skilled at lung ultrasound before considering cardiac POCUS. With an accurate volume assessment, thorough lung exam, and a good history cardiac POCUS is often unnecessary. With these thoughts in mind, POCUS champions are encouraged to consider their near and intermediate-term scope of use in order to accurately identify the needs of their program.

Equipment

The most obvious need of any POCUS program is the ultrasound device(s). There are currently many handheld and cart-based systems on the market, each of which has advantages and disadvantages.^22,42 It is recommended that clinicians and IT personnel research and compare the attributes of many different devices and associated software when considering which devices to purchase. Examples of important attributes to have in mind include software packages for different scanning applications, size/portability, data storage and archiving capabilities, artificial intelligence (AI)-enabled features, battery life, and capability to interface with other institutional software platforms. Other vendor offerings can also be important, such as educational content that is often included with the device or ongoing support packages. Keeping the problem statement in mind while considering equipment will help in this decision-making process.

If the intended use is limited in scope and does not require advanced techniques and processing, a smaller, less expensive device with good ease of operation could be purchased. If the device is to be used for broad applications, including advanced cardiac imaging or artificial intelligence, more expensive devices may be required. It is also important to note that certain devices or separately purchased transducers are not all capable of performing all applications. There are some handheld devices that cannot function as a linear transducer, and hence are poorly suited for imaging of superficial structures. This may be appropriate if the intended use was for cardiac and abdominal imaging but would not work for vascular access or musculoskeletal ultrasound. Some transducers have a narrow footprint, allowing ease of imaging between the ribs which is ideal for cardiac imaging but do not have the same wide field that can make imaging larger structures simpler. Generally speaking, the more focused the functionality, the lower the cost.

The availability of physical space for storage, the number of intended users, and the clinic layout are also important. If there are many intended users or a few users that are physically separated, more devices will need to be purchased to allow for adequate availability. Naturally, this need for a greater number of devices might influence the amount that can be invested per device. In addition, if existing institutional software solutions will be used in POCUS workflows, stakeholders must ensure that purchased devices are compatible with existing software with help from IT experts and device vendors.

Finally, parties responsible for maintenance and upkeep of equipment should be identified. Requirements are minimal for most point-of-care devices but nonetheless should be accounted for to ensure safe and effective operation.

Software

Although portable ultrasound devices can be used in a standalone fashion without interfacing with archiving software of the electronic health record, there is a clear benefit to having the ability to review and compare images easily. Such capabilities are consistent with guideline recommendations and current practice standards in many specialties.^12,43
-45 Some devices include archiving and quality assurance software with device purchase and subscription, which can provide a simplified solution that often has capabilities to interface with devices from other manufacturers. Stand-alone software is also available, which may be advantageous depending on existing institutional software, workflows, and program needs. Clinicians, IT staff, and vendors must work together closely to ensure a solution is found that meets the patient care needs, maximizes clinician efficiency, and integrates well with existing software.

Archiving and Quality Assessment

Best practices in POCUS use include capabilities for archiving images in the electronic health record, regardless of intent to bill, for the sake of quality of care.^23,46,47 Saved images should include sufficient labeling to include organ/tissue/body region imaged if not obvious and laterality when appropriate in addition to patient identifiers. Whenever possible, ongoing competence should be assessed through periodic image review by POCUS experts, which can be incorporated into credentialling/recredentialling processes.^21,48 Oftentimes, especially in larger programs, this is conducted internally. If this is not feasible, agreements could be sought with other departments such as radiology or emergency medicine. There are also consulting institutions that are available to provide this service for a fee. Criteria for review might include use of proper machine settings, labeling, orientation, documentation, and interpretation.

Credentialling

Each institution will determine appropriate credentialing standards, if any, for POCUS use. Early in the course of program development, applying credentialing standards could create unnecessary barriers to uptake. As a program matures it will likely become more feasible to include credentialing standards for users. Conversely, the authors’ experiences suggest that at some institutions, adoption of POCUS may be more acceptable to the institution if credentialing standards are adopted earlier in program development, especially when there is uncertainty regarding safety among stakeholders.

There are some published examples of credentialing requirements, however these are not specific to an outpatient primary care practice.^21,44,49
-51 Important distinctions are notable between the safety and utility of POCUS use in the primary care setting due to the acuity and severity of illness and the nature of questions being answered, which must be considered in policy development. Many institutions that choose to require POCUS credentialing may require both demonstration of prior training as a part of residency/fellowship or formal CME courses and documentation of a mentored imaging portfolio. For example, there may be a pathway for previously credentialled clinicians; whereby re-credentialing could involve continued education, exam counts, and/or demonstration of quality by an expert reviewer.^21,52

It is worth noting that skills in some exam types with high yield in primary care have been demonstrated to be easily obtainable with minimal training which should be considered in credentialing requirements.^53,54 One example of this would be assessing jugular venous pressure for volume assessment in a patient with known or presumed congestive heart failure. The traditional exam is often difficult in patients of larger size and has considerable importance in evaluating and managing congestive heart failure. The fluid meniscus can be easily visualized with ultrasound, and the examination and clinical decision-making are otherwise identical to traditional exams. Although it is of paramount importance that we ensure safe use of these devices, clearly there are circumstances in which the use of ultrasound is the safest option for all but the most novice users. Credentialing requirements should be developed with this understanding in mind.

Documentation, Coding, and Billing

In the inpatient environment, reimbursement for POCUS exams is relatively poor such that the time needed to meet documentation and archiving standards for billing is hardly, if at all, justified by the level of reimbursement in many cases. POCUS has seen broad use in this environment because of the clear and immediate benefit in quality of care. In the outpatient environment reimbursement rates are much more favorable. Moderate frequency of POCUS use and billing in this setting may easily justify the cost of equipment, software, and administrative time. Since time to conduct exams and document according to billing standards is a commonly cited barrier to implementation, it is recommended that outpatient practice groups consider implementing billing capabilities with efficient workflows.⁹ To properly bill for this service, it is generally required that an order be placed for the service, images be archived in the electronic health record with specific labeling requirements and that specific elements be present in the documentation.^43
-45,55 This process can be burdensome if workflows are not designed to maximize efficiency, and failure to capture associated revenue makes it difficult to financially justify the time spent. Much of this process can be automated, and assistance for this process is generally available through software or device vendors.^21,47,56,57 Another great resource for workflow development and system integration is other hospital or clinic departments that have previously implemented these practices. Consider reaching out to colleagues in emergency medicine, critical care, or anesthesia for guidance and support from areas where POCUS has long been the standard of care and their workflows are often quite mature.

Necessary Documentation Elements

I. Date and time of examination.

II. Name and hospital identification number of the patient.

III. Patient age, date of birth, and sex.

IV. Name of the person who performed and/or interpreted the study, clinical findings.

V. Indication for the study, the scope (complete vs limited), and if this is a repeat study by the same provider, repeat by a different provider, or reduced level of service.

VI. Impression (including when a study is nondiagnostic) and differential diagnosis, as well as the need for follow-up exams and incidental findings.

VII. Mode of archiving the data (where can the images be found to be viewed).

Program Leadership

Most successful and robust POCUS programs owe much of their success to clinician leader(s) who oversee and coordinate these efforts. Not only is the effort great in program development, but successful maintenance and sustainability depend on continued efforts at ensuring quality, coordinating multidisciplinary efforts, supporting other clinician users of POCUS, and ensuring institutional practice standards are up to date and met. Time must be set aside and financially supported to complete these tasks.²³ It is recommended that analysis be conducted of the estimated time required for this purpose and that this be incorporated in any plan or proposal. POCUS leaders are encouraged to benchmark this need against other departments in their institution or outside institutions with a program of similar size and scope. Networking within professional societies or ultrasound organizations is an excellent way to make connections for this purpose.

Evaluation

To ensure program success and identify opportunities for future improvement the program should be objectively and formally evaluated at regular intervals.²³ Planning for this evaluation before implementing a POCUS program is recommended such that it is seamlessly incorporated into the program and can go forward more smoothly. The method of evaluation is ideally simple and directly answers whether the program is successfully addressing the identified problem. For example, if one of the identified problems is that excessive referrals to urology for benign prostatic hyperplasia (BPH) are occurring in men with nocturia that is not due to prostate or bladder pathology (eg, lifestyle factors or sleep apnea), and a focus of the intervention was to encourage assessment of post-void residual bladder volumes in office, one could compare the final diagnosis of patients referred to urology pre and post-intervention. If one of the stated problems is that inefficient workflows dissuade clinicians from using POCUS, simply following the number exams of any type performed over time would be sufficient.

It may be prudent as well to consider potential harms in evaluating the outcomes of implementation. For example, overdiagnosis or misdiagnoses are common concerns raised about POCUS use in the experience of the authors. If there is an opportunity to compare POCUS findings to formal imaging findings or assess downstream utilization of services this could alert POCUS leaders to opportunities to improve the practice.

Secure Operational and Financial Support

Once these steps are complete, a program outline and proposal can be drafted, including all the elements above. It will likely be necessary to gain financial and operational support from administration for the program. The most effective proposal will also include a return-on-investment analysis if possible. This analysis could take many forms and will vary by proposed indications for use and several other local factors, such as patient characteristics, payor mix, and ancillary testing availability, etc. Data analytics, health information management, and billing specialists will be crucial partners in this step. Collaboration with other experienced departments can also be helpful. Stakeholders are encouraged to include financial returns as well as other benefits of the program in this analysis and proposal, such as improved educational experience to attract students, improved patient experience and engagement, and improved clinician experience. Administrators are likely to respond more favorably to proposals that include baseline data, clear demonstration of a need, clear plans for implementation, and plans for program evaluation and maintenance.

Sustained Engagement

After the POCUS program has been deployed and 1 iteration of the evaluation is complete, intentional measures are advised to maintain engagement of stakeholders, ensure continued quality improvement, and support existing users. In some cases, especially in larger institutions, committee formation to oversee the various facets of the program may prove beneficial. Scheduled review through practice, credentialing, or quality committees is advised. It is recommended that an ongoing review of the program be conducted at regular intervals, and that consideration be given to adding or modifying the problem statement and subsequent evaluation plans based on assessment findings or newly identified opportunities for improvement. Hosting or supporting educational opportunities is an excellent way to keep users involved and maintain competence. It will likely prove beneficial for clinician leaders to engage with local or national ultrasound or POCUS organizations, or specialty college interest groups to stay up to date with current practices and to continue to bring educational content and practice updates to group members.

Summary

We hope this documentation serves as a valuable framework for clinicians and/or administrators wishing to expand the use of POCUS in primary care or other outpatient environments. This is intended to serve both as a framework for implementation as well as a discussion of best practices toward which to strive. We recognize that the effort required may appear exceptionally great for clinicians in systems that are smaller or more resource-limited. Know that it is not our intent to suggest that the totality of this framework must be employed and in place for responsible POCUS use, but rather that this could be considered a guide or checklist of available options from which users could customize a program to their needs and capabilities. Some options are necessary, but others can be foregone or deferred depending on the institution’s needs, resources, and local practice standards. Those seeking to institute a POCUS practice are encouraged to focus first on the needs of their patients, communities, and healthcare workers to design a program that will provide the greatest benefit to all while minimizing risk.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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A Clinician’s Guide to the Implementation of Point-of-Care Ultrasound (POCUS) in the Outpatient Practice

Abstract

Keywords

Background

Define the Problem

Identify Stakeholders

Assess Needs

Definition of Scope

Equipment

Software

Archiving and Quality Assessment

Credentialling

Documentation, Coding, and Billing

Program Leadership

Evaluation

Secure Operational and Financial Support

Sustained Engagement

Summary

Footnotes

Declaration of Conflicting Interests

Funding

References