The Present State of Diagnostic Ultrasound A View From 10,000 Feet - HD

Introduction

Good morning.
I'm John Cronin.
I'm chairman of Diagnostic Imaging at Rhode Island Hospital
in Brown School of Medicine.
Today I'm going to talk to you about ultrasound
and does it have a future in diagnostic imaging.
Today I'm gonna share
with you my thoughts on the present state
of diagnostic ultrasound,
but at a very high level, where we are
and where we are going.
I have no relevant financial relationship to disclose.

The Ubiquity of Ultrasound

Let me start by saying that ultrasound is ubiquitous
and everyone thinks they can perform ultrasound.
I have a list here, which is probably only a partial list.
Every single medical specialty at some level thinks they can
perform ultrasound.
We certainly are no longer the owners of this particular,
imaging tool.
Matter of fact, this week,
a article came out showing
that radiologists no longer predominate in performing
ultrasound guided procedures.
This is from September, 2013,
and it shows that radiologists are not the number one
utilizers of ultrasound
and the performance of guided procedures.
Clearly a marker that ultrasound has now
established itself in all of medicine
and not just something in radiology.

Today's Changing Environment in Diagnostic Imaging

Today's environment is a little bizarre
and rapidly changing.
Radiologists universally in the United States are working
feverishly to maintain their income.
As cuts have been made in reimbursement,
you just work harder and harder.
The radiologists are acutely aware
that the higher reimbursement is awarded for MR
and ct, not for ultrasound.
Also, outpatient imaging centers, which focus on MR
and CT, have been very proliferative
in the last two decades.
AIDS technology has advanced in MR
and ct, MR Body.
MR has become very well developed in the
last five to 10 years.
CT now has multi detectors, which are rapid devices to
interrogate a large part of the body.
Ultrasound really has nothing technically new in the last
decade, perhaps two decades,
compact ultrasound has come along.
While it doesn't necessarily appeal to radiologists as a
impact factor, it has appealed to non radiologists.
Then of course, greed is a terrible thing in
self-referral predominates in all of FIFA service medicine.
There's also the concern for radiation.
Today's environment is extraordinarily complex,
but one with all
of these factors influencing what's happening,
perhaps the genesis of the
horse leaving the barn
for ultrasound, leaving diagnostic imaging was the A MA in
2004, establishing a policy statement saying
that ultrasound is within the scope of practice
of all appropriately trained physicians.
It did not belong to a single specialty
and any particular specialty could use ultrasound
and should be allowed to use it.
And you note in number three here, it should
hos medical staffs at hospitals should be specifically
focused on allowing each individual department to determine
what the privileges were to obtain ultrasound
privileging in a hospital.
In addition to a year later in 2005, it said
that the a MA would actively engage in the pursuit
of preventing people re trying to restrict ultrasound
practices to other specialties
and limit it to one specialty.
Obviously, the focus here was radiology trying to limit it.
And the a MA took a very strong stance
that they were not in favor of that,
and that it ultrasound belonged to everybody.

Impact of Radiologist Shortages and Reimbursement Pressures

Now, you'll notice in the next slide, I implied that
with the shortage of radiologists.
And up to about two years ago, the shortage
of radiologists was a key element
in influencing the utilization of ultrasound.
Today, there's less of a shortage,
but there's still the impetus to maximize efforts
with higher reimbursement.
So with decreasing reimbursement
and the increased demand for services, radiologists have
to increase the workload
and work harder to maintain their income.
In that world, there are some things they may not be willing
to do as much, and
therefore they're surrendering that turf to other specialties,
relinquishing responsibility becomes the norm.
You say, I can't do portables.
Let them do them on the floor.
Let them have their own handheld units, for example.
And we focus statin radiology on high end procedures,
procedures that are going to give us high reimbursement.
And ultrasound is essentially reshaped by this scenario
because it is not a high-end reimbursed procedure.
Radiologists can't do everything in order
to maintain their income, maintain what they do.
They focus on the high-end procedures
and tend not to focus a lot of attention
on ultrasound.
If you look in our practice in
at Rhode Island Medical Imaging at Brown University in our
outpatient practice, this is a pretty telling delineation
of what's happened.
So relative value units, RVs are the
barometer used to determine what you're going
to get reimbursed for your effort.
So we looked at our outpatient offices just to get a handle,
and in 2011,
we performed 22,179 ultrasound exams.
That was 20% of the office volume of all exams,
yet it accounted for only 8% of the RVs.
We did 14,000 MRI exams, which is only 12%
of the office volume, yet it accounted for 28%
of the RVs showing you that
MRI was rewarded at a much higher rate
of reimbursement since the RVs completely determines your
reimbursement than his ultrasound.
So the determination that was made previously to give r
and CT high RVU numbers
and ultrasound low numbers has many ways determined the fate
of ultrasound and diagnostic imaging.

Vendor Involvement and Market Shifts

In addition to all this, the vendors have really caught on
to the fact that there is a huge market out there
for ultrasound, but not necessarily in diagnostic imaging.
Now, other people don't know how to do imaging necessarily,
but the vendors are now offering a soup to nuts,
turnkey operation, a vertical integration
where they will come in, put a unit in, set up to you,
it will stall it, train you, teach you how to bill for it,
provide the service, the marketing.
You don't even have to buy the unit. It can be leased.
So it's vendors have focused on this turnkey operation
with vertical integration, allowing OBGYNs, internists,
surgeons, orthopedists, anybody who really wants
to do ultrasound, they're willing to help them set it up.

Current Challenges for Ultrasound in Radiology

So let's just frankly look at what ultrasound has today.
It has a lower reimbursement. The technology's flat.
We've been holding out the hope of contrast approval.
It hasn't happened. Compact ultrasound has come.
We didn't embrace it in radiology,
but the rest of medicine has.
Ultrasound requires input
and involvement by a physician.
MR
and CT tend
to be programmed techniques the patient has The exam doesn't
require the physician to be involved.
They can read at a later time.
Many ultrasound exams require the physician involved
to be involved with the case
and to see it in real time to some extent
to get a very good study.
So the ultrasound has become somewhat less attractive
to the practices of radiology
and tends to actually put on the back burner.
Additional factors, very few residents are pursuing
ultrasound fellowships.
The predominant fellowships, resident seeker, MSK
and neuro training programs don't have any expert in
ultrasound in their department.
So if you have a residency
that doesn't have an V ultrasound advocate,
there's a real problem here.
So ultrasound has less interest in training.
The cts scanners are becoming better.
Abdominal MRIs becoming better.
Compact ultrasound is out there floating around sometimes,
everybody's walking around the floors
with the compact ultrasound,
and technologists are in short supply.
The other aspect is the fusion
of imaging into other specialties.
As we have allowed the other specialties to develop,
they have realized the importance of imaging in their
in their day-to-day practice.
PACS and teleradiology, particularly Pax,
has placed imaging availability at the site of the,
of the primary care or the specialty physician.
They no longer have to come to the radiology department
to see the exams.
We no longer control the exams.
They're now ubiquitous because of the PAC system.
So service line imaging's developed where you now have
a prostate center where imaging
for the prostate's done there.
An oncology center where imaging's done there,
a spine center where the imaging is done there.
Imaging is even dispersing out of the radiology department.
It is imaging is integral to the practice of medicine,
and we're seeing it become owned by many people.
Ultrasound at the point of contact improves patient care.
This is why the ER docs are such strong advocates
for ultrasound in their world.
Ultrasound point
of care ultrasound really can give gold directed in
information about the patient.

The Perfect Storm and Commoditization

So ways this tur Fisher lead us well, there's an inability
of radiologists to supply all the services necessary.
Other practitioners are eager to get involved.
And self-referral is an acknowledged practice in the
United States where you can actually order an exam,
do it yourself, and get reimbursed for it.
So it is a very interesting profit center
for many practices.
So it creates a perfect storm.
We have a lack of interest for ultrasound by radiologists.
You got self-referral compact ultrasound.
The ER is advocating. They need to have rapid turnaround.
They need to make diagnosis at the point of care.
They need the units. We don't have enough trained
technologists to provide 24 7 coverage.
Our technology is relatively stagnant.
Reimbursement is relatively low for ultrasound,
and ultrasound is perceived instead
by the medical community.
As a new stethoscope, it's used by all
and the commoditization of imaging, it means that sort
of you buy a paperclip, you don't really care
what name it is on the paperclip or what brand it is,
and ultrasound sort of becomes, well,
all ultrasounds are equal and you just order an ultrasound
and it doesn't make any difference who does it
or who interprets it.
A real fallacy. But something that I think is true
as commoditization occurs.
And then radiology is kind of right now in a funk.
Radiologists are working very hard.
There's a shortage of workforce to some extent.
That's margining somewhat.
Radiologists make a fair amount of money.
They have more
and more the younger people have an employee mentality than
aren't really out to grow things.
They're content to do what they do.
And there's always a sense, it's not gonna happen to me.
The older guys think this is doom and gloom.
Again, I've heard this before
and radiologists somewhat unfortunately with pacs,
the interpretation in isolation have isolated us from clinicians who basically are
provided reports almost instantly
and are able to look at the images themselves
and don't come and talk to us.
And it has created a real isolation of the specialty.

Compact Ultrasound as the Trojan Horse

Compact ultrasound.
It is the Trojan horse.
It allowed everyone entry into the field
of ultrasound inexpensively and without much control.
It's a disruptive technology.
It's cheaper, smaller,
and very efficient at what it does.
The radiologists
who looked at this in the beginning still fell in love
with the large, big fixed units,
and there's no doubt they provide better quality.
And many in radiology have a
denigrated the compact ultrasound much the same way we
denigrated small, small bar MRI units.
And that actually brought the demise of those units.
But the compact ultrasound, we contested,
they were not as good.
But that didn't change anything.
It moved into the field of medicine.
Radiologists have been accused by some of being Luddites.
Luddites are people who oppose advancements in technology.
Jeff Lu was a weaver in England in an 1811,
led a band of weavers
to smash these new mech mechanized weaving machines
that they found threatening to their trade from that raid
that occurred in the middle of the night.
The name Luddites then was espoused to those people
who opposed new technology.
Radiologists have been considered to be ludite somewhat
with regard to compact ultrasound.

Ultrasound as an Extension of the Physical Exam

Ultrasound in some ways is an extension
of the physical exam.
It's like the stethoscope.
It's used by every specialty
and each specialty has a certain level of expertise in it.
It offers, it certainly offers the potential
to improve patient care.
Our opposition to compact ultrasound in many ways brings us
to be accused of being Luddites.
Roy Philly probably had a
premonition of where we were going.
He said that diagnostic ultrasound truly is the
next stethoscope.
It's gonna be used by many and understood by few.
And he said that in 1988.
When you think about it, you see hospitals, cardiologists,
maybe the most competent people with the stethoscope.
However, the ability of the stethoscope
to be used by the nurse practitioner
or for the aide, for example, is not necessarily equivalent
to the cardiologist much
as the way the ultrasound can be used
by many different people,
but not necessarily with the same level of expertise.
Ultrasound is primarily office based,
and that is the initial inroads to everybody to practice it.
So you can have rheumatologists, breast surgeons,
endocrinologists using ultrasound in their office.
Credential is essentially non-existent in the office
for radiologists.
The impetus or the
or the barrier for other specialties to get involved
with the technique was they needed hospital privileging.
While hospital privileging isn't necessary for ultrasound,
because it is used so often in the office practice,
it has very few side effects or any recognized side effects
and allows many people to just buy the unit
and start practicing.
So in the emergency room, that is the point of contestant
for many radiology departments
because it's in a hospital setting
that the ER docs are using these handheld
units on the floors.
Everybody's using handheld units for vascular access.
Thoracentesis and paracentesis, they use a handheld unit.
They're not using radiology involvement
and everyone's content
to let just about anybody pick it up much as they're
with a stethoscope and use it to guide a procedure.
So you have this crazy world we have today
where you have lack of fellowship trained individuals.
We have turf erosion, a shortage of radiologists devoted
to ultrasound for sure, compact ultrasounds everywhere.
We have our own technological competition coming from MRI
and CT offering, alternatively, better techniques
and ultrasound perceived as the new stethoscope.

The Future of Ultrasound

So where is the future of ultrasound?
Well, clearly it's diffusing into all of medicine.
So every specialty is gonna have a foothold
or a utilization of this much as they do the stethoscope.
It's less of a frontline tool for radiologists.
It's used by radiologists.
But truly many radiology departments focus on Mr.
CT as ways to initially look at things
and look at ultrasound.
More of a boutique for specific utilization.
It's really become the stethoscope of the future.
As Roy had told us, it's used by many physicians
to improve clinical certainty,
and it's understood by very few.
What is really more telling of its future is
that it ultrasound is being incorporated into,
into the curriculum
of basic medical education in many medical schools.
And in many of these schools,
the ER physicians are taking the lead in introducing this.

Conclusion

So that wraps up our presentation today on the future
of ultrasound and diagnostic imaging.
I think it has a great future in medicine
and a questionable future in diagnostic imaging.