Point-of-care ultrasound: addressing the barriers to wider adoption

Butterfly ScanLab in action at Kansas City University (KCU). Credit: KCU

S​​​​​​​ince arriving in emergency medicine and critical care centres in the US in the ‘90s, point-of-care ultrasound (POCUS) devices have rapidly become a standard of care. In the US today, becoming an emergency room (ER) physician requires proficiency in 11 different POCUS scan types and for prospects to have performed at least 150 scans.

However, POCUS also holds great potential for adoption in primary care settings.

Instead of detecting, for example, a heart murmur that needs further evaluation, and would require a patient to be scheduled in for another appointment, potentially up to several weeks later and with a different practitioner, at a specialised centre with a traditional ultrasound machine, POCUS enables the consolidation of these steps. Therefore, for primary care, as in the ER, a comprehensive diagnostic evaluation can be completed with a single evaluation.

“One of the drivers of POCUS’s rising adoption in primary care setting was Covid, with bedside ultrasound and portable ultrasound systems found to have similar sensitivity and accuracy for particular procedures that used to be analysed via traditional ultrasound or through the use of other medical tests,” says Ashley Clarke, senior healthcare analyst at GlobalData.

According to Clarke, in the US, handheld systems have the highest growth value out of all ultrasound systems – at a current rate of 3.75% annually – with the upfront acquisition cost for these and other devices classifiable as POCUS considerably lower, costing between $5,000 and $20,000 on average, than traditional ultrasound systems that may cost anywhere from $50,000 to $200,000.

“This lower upfront cost is part of what is driving the market and making POCUS appealing to public medical facilities or research-related centres like universities,” says Clarke.

According to Clarke, the key barrier towards greater POCUS adoption in primary care in the US comes down to a lack of training.

“These devices have been useful for quite a while in emergency and critical care settings, but they’re slower to be adopted by primary care providers, just because of that training issue.”

A studyof 105 Veterans Affairs (VA) medical centres , published in the American Journal of Medicine, found that a lack of trained providers and funding for training were the most common barriers to POCUS adoption, at 78% and 41% respectively. Meanwhile, a study of rheumatology chiefs at VA centres in the US again cited a lack of trained providers as a barrier, as reported by 68% of respondents, with 69% of those surveyed expressing a desire for training for their group.

Another potential barrier to POCUS’s adoption in US primary care settings, relates to billable hours.

“Since this isn’t a device that has been used in primary care for a very long amount of time, there’s still some confusion around how to correctly go about collecting all of the proper documentation and connecting it with existing healthcare IT to make sure all of the data is saved appropriately to get that billable hour back,” explains Clarke.

“Once these barriers are overcome, we expect to see a much higher growth for these devices coming to market.”

Kansas City University (KCU) recently transformed its POCUS curriculum with a view to availing medical students with hands-on competency in using the technology before they enter medical residencies.

The fifth biggest medical school in the US, KCU has partnered with device company Butterfly Network and made its ScanLab ultrasound device the core of its POCUS curriculum.

ScanLab is an artificial-intelligence (AI)-powered handheld POCUS system that provides students with feedback and guidance intended to help strengthen skills in essential scans including cardiac and lung. The app offers real-time anatomical labelling, step-by-step instruction, feedback on probe placement, and can compare students’ scans to reference images.

As one of the few KCU faculty members with the expertise to teach POCUS, for Dr Robert Arnce, director of clinical integration at KCU, teaching up to 400 students on how to use POCUS was once a tall, time-consuming order.

“Ultrasound is a hands-on thing. I can’t just throw a slide up and expect students to learn how to do it, because there’s the image acquisition, interpretation of the image, and so on. Therefore, the game changer for us is AI.”

With ScanLab, Arnce says he is now able to put together pre-recorded lectures on how to obtain images, while the majority of POCUS learning is self-directed with ScanLab’s AI provision.

The possibility of self-learning is made possible by the relatively lower cost of Butterfly ScanLab, given it would not be possible to provide each student with a $65,000 ultrasound system the likes of which Arnce uses in his work as an ER clinician.

“When I started using Butterfly to teach, the price point was somewhere in the $4,000 range, so it’s not out of the realm of possibility to have an ultrasound in every student’s hand, and that’s a large part of why Butterfly made sense for us.”

According to Arnce, students who have gone through the KCU POCUS curriculum stand out when applying for residencies due to their competency in using the technology.

“When you’re looking at an applicant, distinguishing one candidate from another comes down to how students perform when they’re on audition rotations during residency.

“I’ve had multiple students who’ve thanked me for the POCUS training, because they were, for instance, working in the ER and had a trauma come in, and other residents couldn’t get the scan, but they could.

“If POCUS is a skill you already have, it’s one less thing you need to learn, and it’s one thing that you do better than your peers, and so it puts individuals in the driver’s seat in terms of future success,” Arnce concludes.

Along similar lines to KCU, GE HealthCare recently launched  Venue, a family of POCUS devices equipped with AI.

According to Karley Yoder, general manager, POCUS, and chief digital officer, Ultrasound at GE HealthCare, advancements in AI in ultrasound are helping healthcare providers make more informed decisions faster and manage increased demand.

“AI helps unlock the full potential of ultrasound technology by enabling smarter scan guidance, greater workflow productivity, and more informed clinical decision support. AI-powered solutions expand access to scans by enabling a wider range of healthcare providers to perform cardiac exams with real-time guidance at the point of care,” says Yoder.

“For example, Caption Guidance AI-driven software, available on Venue family ultrasound systems and Vscan Air SL with Caption AI, enhances cardiac care and alleviates the burden on sonographers and radiology departments by empowering more clinicians to perform scans and triage patients. This includes software features like AutoEF that can automatically calculate a left ventricular ejection fraction. AI tools ensure consistency across users, whether they are experts or non-experts.”

While some people may be to figure POCUS out by themselves, Global Ultrasound Institute (GUSI) co-CEO Kevin Bergman notes that this often leads individuals down a lot of blind pathways and proves inefficient.

“Just like with anything else, you learn from people who’ve been there, done that, and who can actually teach it to you properly,” says Bergman.

And this, given that awareness of the usefulness of POCUS outside of its original ER setting has risen, along with people’s desire to be able to use it but not being trained on how to, is why GUSI recently launched its online fellowships platform, to fill the skill gap and help get practitioners to a state of competency in using POCUS systems.

Bergman describes this current phase in relation to POCUS as having been a “lag time”, noting that the general way people learn how to be a doctor or healthcare practitioner is in medical school and in residency.

“If you didn’t learn something in that period of time, it’s extremely hard to learn it afterwards when you’re already in a busy practice.”

According to Bergman, there have not historically been many apt ways to get learners to competency in POCUS.

“People can perhaps go to a workshop, but that may be like one day, for several hours. But to acquire this skill and be confident and competent, it takes months. After some initial training, learners must practice a lot, perform scans, and get feedback on them, and through that process of feedback and learning, they start to get to a point where it begins to make sense.”

With this in mind, GUSI’s fellowship has been designed as a comprehensive 12-step learning pathway for different scanning modalities – which users can select depending on what sort of healthcare practitioner they are and complete at their own pace – and features a mix of video didactics, real-time mentorship, and a final exam.

POCUS learners are also able to upload practice scans they have made and get feedback on them.

Throughout the fellowship, which generally takes learners around three months to complete, they are connected with one of more than 500 qualified evaluators who provide mentorship. The 1:1 mentorship sessions provided throughout the fellowship connect the mentor to the learner’s screen of whichever scanner they are using, enabling mentors to offer real time guidance and feedback as learners perform scans with their POCUS device.

Learners eventually undertake a multiple-choice exam and what GUSI calls a real time observed, structured clinical exam (OSCE) involving a checklist of things learners need to evidence that they can do.

“If they achieve a score of 80% or above in these areas, then they’re able to pass, and we grant them a certification of competency indicating they are now qualified to perform POCUS at their institution,” says Bergman.

As far as Bergman is aware, no comparable course to GUSI’s fellowship for POCUS is currently available.

“We’ve been teaching POCUS and operating in this space for a long time, and there’s a lot of in- person course opportunities, and online videos, but this was the missing link, of actually being to take a learner through a whole vetted process and get them to a point where they are able to safely do this in patient care.”

Robert Arnce shared that some people in the ultrasound field have coined POCUS the ‘stethoscope of the next generation’. With the rise of curriculums teaching POCUS at the university level, and with the emergence of comprehensive training initiatives to give older practitioners the opportunity to learn POCUS in a structured, validated way, they may just be right.

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