Contact Sales
Duration:
Broadcast:
Topics: Admin, BioMed, Clinical Educator, and Informatics
Related
Subscribe

Never miss a webinar!

https://www.youtube.com/watch?v=nsaVFWGfXD0
Transcript

- Welcome to the Sonos site

behind the scan webinar titled Beyond POCUS Archiving.

Why is it so important?

My name is Chris Pennell

and I'll be hosting today's webinar.

Before we begin, please be advised all attendees are muted,

and as the discussion is going,

you can type your questions into the q

and a box at any time in the toolbar located at the bottom

or the side of your screen,

and we'll get to those questions at the q

and a session at the end of the discussion.

This webinar will be recorded

and archived for future reference on our webinars page on

sonosite.com.

So here with us today leading

and moderating the discussion, we have Dr.

Colin Bell. Colin is an emergency physician in

Calgary, Alberta, Canada.

He's active nationally within the CA Canadian POCUS

community and is currently the clinical practice lead

for the CAEP emergency ultrasound committee.

Colin was previously the POCUS director

for the emergency department at the Kingston

Health Sciences Center.

He completed his POCUS fellowship at the Denver Health

Medical Center in 2016.

Colin is active as a POCUS researcher

and his focus is POCUS education

and automated technical skill assessment.

He's a passionate advocate for image archiving.

With that, I'll turn it over to Colin to get started

and introduce our other panelists.

- So POCUS is a disruptive force within medicine

and until recently there was a traditional workup

and diagnostic pathway for most patient presentations

and subsequent diagnoses.

POCUS disrupts this often front securing a diagnosis far

more quickly than traditional processes,

and this causes tension as the patient

and provider wait for the rest of the system to catch up,

often needlessly tying up additional resources.

On the contrary, there may be a lack

of consultant confidence in the security of such diagnoses

as this often hinges on laboratory medicine,

consultative imaging, and clinical reassessment.

And some non-ED consultants do not accept

or have not accepted the validity of POCUS are kept up

with its considerable progress.

Over the recent past noncritical,

patient interactions are often initiated

by the computer rather than the bedside and history

and physical exam and isolation rarely meet the bar

for exposing patients to possible harm.

One needs more than a story to engage consulting services,

a robust picture archiving

and communication system where PACS serves

as an effective communication tool

to engage Consultants provide an avenue

for quality assurance and generate additional income

for emergency departments.

But traditional PAC software is in flexible.

Think of the last time you ordered a portable chest x-ray

without submitting a requisition.

PO is a diagnostic

and interventional tool occurring at the bedside in real

time and over time it becomes more

ingrained across medicine.

Middleware is a software solution that simultaneously acts

as a bridge between other software databases

and hardware contemporaneously functioning

as a holding container for POCUS studies,

it's a communication tool in the clinical realm

and facilitates education research.

An advantageous characteristic for middleware is

to have the adaptability to compile examinations occurring

under various POCUS workflows.

So thinking about diagnostic

and interventional studies, think of the breadth

of different studies you do in your department

and in other areas of the hospital.

Think of critical resuscitation scenarios as well

as typical diagnostic workflows.

How from middleware has significant functionality in

rectifying and complete data linking studies

to patients facilitating image stores, communication,

reporting, and assisting and billing.

So today's objectives are to identify the difference

between storing images and pacs

and utilizing POCUS specific middleware to understand

how a POCUS archiving

and connectivity program can support quality improvement and

or credentialing programs leading

to enhanced clinician proficiency to gain insights on how

to communicate using the connectivity of POCUS archiving

and how to understand

how specific POCUS archiving software can facilitate billing

and appropriate POCUS scans can

increase return on investment.

So throughout our discussion today,

we're gonna focus on a few themes, the characteristics

of a POCA specific middleware for clinicians

and consultants, their interaction with the middleware,

the interface for quality assurance,

and the interaction with electronic medical records.

Our panelists today are Dr. Rob Ferry. Dr.

Ferry is a Utah native.

He graduated from the medical school at the Medical College

of Wisconsin and completed his residency at the main Marine

Medical Center, sorry, the main medical center.

He did three years of active duty

for the United States Air Force, completing two tours

of duty in Iraq, after which he completed an emergency

ultrasound fellowship at Palmetto Health in

Richland, South Carolina.

Dr. Ferry spent nine years at Vanderbilt Medical Center,

subsequently where he founded the emergency department

ultrasound fellowship and the emergency ultrasound division.

He moved to Indiana in 2019 where he currently serves

as the POCUS Division chief in the

Department of Emergency Medicine.

Our other panelist is Dr. Hippskin. Dr.

Hippskin iss, a board certified emergency physician in

Visalia, California.

He's an assistant medical director

for the emergency ultrasound fellowship at Health.

John did his residency at Cook County in Chicago in 1995.

Prior to the widespread use of pocus.

He was an early adapter using the radiology leftovers.

Listened to ultrasound based podcasts

as they became available,

and then subsequently completed his POCUS fellowship

through the Ultrasound Leadership academy.

He's now an advanced emergency medicine focused practice

designated ultrasound through Abe M.

He's a POCUS educator

and he focuses on optimizing end user workflow

and improving coding for billers

and reimbursement for others.

So with that, we'll start our first section,

which will last about 20 minutes on the

fundamentals of pocus.

So for our panelists, why do you believe it is important

to document POCUS exams in the emergency department?

- So Colin, thanks, glad to be here.

Excellent question. So, you know, I, I think, you know,

as I'm getting old and I've been around

and seen sort of the evolution of how we've used point

of care ultrasound, I would say that

the reason why documentation's important is

because, as you sort of mentioned in your introduction,

that's how we legitimize what we're doing.

So in other areas of medical imaging, we need to document

and show that we're documenting what we're doing.

And so because point CARLSTONE is an imaging tool, we want

to demonstrate for downstream providers

that we've done an exam, these are the findings of the exam.

And as point of sound grows, the good news is, is

that these downstream physicians,

clinicians actually also know how to look at these images,

know what they mean, and also can understand the

clinical significance.

So that, so to me that, you know, not only is it important

for medical-legal reasons,

but as we grow point of care ultrasound, it's important

because it provides very useful clinical information

for those physicians, especially

as point of care ultrasound grows.

- Yeah, I think those are all good points

and also glad to be here today.

We can also more effectively

communicate within the department.

So you, when starting a patient's workup

and identify a problem right up front,

that documentation helps some

of your ED colleagues in addition to which are some

of the downstream providers as well too, in addition to some

of your inpatient consultants.

So getting it all down in a, in a format

that they're becoming more increasingly comfortable

with is, is very important.

And again, it allows to, allows one to optimize

patient care and to, to put that down there so

that others can follow up on

what you've started for the patient.

- Perfect. So in that vein, tell me

what you think the optimal process is versus kind of

what this baseline standard should be.

- So the optimal process is

that there's a computer chip in my brain, it can see

what I do and it can document it for me, right?

That would be the optimal process, but it doesn't exist.

But I, I think that, you know,

unfortunately there's,

there's going to require, there's gonna be some need

to do something extra, right?

I mean, I think for a long time using point

of care ultrasound, we did what I, what I usually

use the term we had bad sonographic hygiene in,

in other words, we picked the machine,

we went in this patient's room, we did the study,

and then we like cleaned it off

or maybe cleaned it off right,

and then rolled it back to where it needed to go.

As we use this more and more

and we understand the importance of documentation, we need,

we recognize that there's a need

for good sonographic hygiene, meaning that I need to go in,

I need to put the patient's information in, I need

to identify myself,

and then I have to go into another program, which, you know,

you've talked a little bit about why we need that to be able

to document those exams and then get them into the EMR.

And so I, I think, you know,

before we had the capacity to marry images from the study

with some type of documentation,

we may just have written in our note, you know,

fast exam negative

or you know,

lung ultrasound demonstrates pleural effusion, something like that.

But ideally we wanna marry those two things together.

And so fortunately we have programs, workflow solutions

that allow us to do that,

but it does require a little bit of extra work

and it requires a little bit of upfront training, you know,

training how to have good hygiene, sonographic hygiene so

that we can begin

to develop habits that allow us to do that.

- Yeah, optimizing the workflow really is

what is the minimal amount of learning

and upfront work for each patient required so

that the end user can basically focus on the patient.

So how, what's the least amount of work that that's seen

as superfluous

but necessary so that you can spend more

of your time on the exam, making those clinical decisions

and then yet somehow, and then getting 'em into the chart.

So yeah, optimal is focused on the patient least amount

of work and hopefully having a good software solution to

to, to make those make that happen.

- So John, with that answer, it sounds like you think that,

you know, readily accessible images really empower providers

to, to take action on what they find and identify, whereas

before with,

with Rob's suggestion about when we had more poor

sonographic hygiene,

it sounded like it was a little bit more challenging to say,

Hey, this is why I did, you know,

why I exposed possible patient to possible harm

by prescribing X medication

or performing y intervention, especially if things didn't go

as smoothly as you'd like

or they came back in a few days with a complication.

So it sounds like POCUS images really help clinicians feel

confident that in their decisions,

talking specifically about middleware interfaces, so tell me

what the standard workflow is at your center.

- So for, so for hours our standard workflow

looks like similar to this.

So we have a barcode scanner,

and I'll tell you the barcode scanner was a revolutionary

item in terms of helping people do,

helping my colleagues, you know,

practice good sonographic hygiene, right?

I mean it was helpful to put the soap dispenser in the

bathroom, right, to help them a little bit in doing this.

So we have a barcode scanner that does

an auto query of a work list.

So we use an encounter based workflow, meaning

that I don't place the order before I do the study.

So in order for me to have an encounter based workflow,

I have to have some tools, some software tools

that have been created that allow me

to document who the patient is.

I don't think I'm gonna have anyone,

but my most

excited sonographer physicians actually type in all

the patient information.

So by using a barcode scanner, I'm able

to accurately query a work list

that then can pull down the patient's information.

We then use a field

and the patient information screen

to identify the person doing the study.

So the operator

or performer of the study, they go off, save their images,

open the software solution

after they've com completed their study,

document their findings,

and then have the ability at that point to either send it

to the electronic medical record

or if I have learners that are learning how

to do ultrasound, they then essentially send it to qa

but don't send it to the electronic medical record.

So one of the great things we haven't really talked about is

that one of the reasons

to document ultrasound is for learning, right?

We need to see that as, as experts that those learning

to do the study can perform technically adequate

images and that their interpretations are correct.

And so some type of middleware solution allows me

to filter those studies so

that I capture those educational studies

and not send them to a clinical product like a PAX

or an EMR, right?

Because they were never meant for that.

They're meant for, for educational reasons only.

And so having that final step that allows the user

who did the study to say, oh yeah, this was just educational

or No, this was part of the clinic,

patient's clinical care allows that filtering to take place.

- Yeah, we have, our workflow is more of

an order based system,

and so there's a couple ways patients entered in the system.

So we're all familiar with the kind of the crash patient

that comes in either unannounced or comes in

and needs immediate clinical care.

So those patients, the, the, the,

they can be scanned, have the study done, and then

after the fact, so to speak, then the person

that did the scan can enter their data

and then enter the patient's data.

And some of that can be prompted with a barcode scanner,

which really cuts down on the, on the work list,

on the work demands.

And some of it can be done

with manually.

So just trying to figure, that's one way of doing it.

The other way is if a more stable patient

that has an order placed, then that patient is found on the,

on the, on the, on the unit and the patient is studied

and then the provider assigns themself,

whoever does the imaging,

and then that person can actually can elect

to record the results in the room on the machine

or if they wanna sit down and look and do it at the desktop.

So there's a couple

of options depending on the acuity of the patient.

And, and depending on the, on the workflow,

sometimes if you're going from room to room, it's easier to,

to do it at the bedside on the machine.

Other times it may make more sense to sit down

and actually do it at the workstation.

- So it sounds like you know, both

of you have slightly different workflows

for your stable patients and a very similar workflow

for your unstable patients.

And that really encounters or,

or encompasses kind of the breadth of, of pocus.

Sometimes you go in to encounter a patient,

you're not really sure if you're gonna actually perform a

study or not, depending on what the complaint is, right.

Oftentimes we find that

what we get in the computer is not quite the same as

what we end up getting a little bit further down the line.

So what happens if there's an error in input?

How do you, how is that fixed? How is that rectified?

- Yeah, great question. So, so

there's a couple of places where the error may occur

and where the error occurs sort

of impacts how you correct it.

So you know, in, let's just say in a common scenario,

most ultrasound machines,

if I don't put patient information in,

create a time date stamp down to the hundredth of a second,

that allows for a unique identifier.

And really what, that's what the ultrasound machine's just

simply trying to do is trying to put in that ID field

or the MRN field that we would usually typically use

and a unique ID so that another ultrasound exam

that was started at a similar time is

unique enough that it can be differentiated from

another ultrasound exam.

So being the fact that that's mainly what happens

if someone runs in there

and for whatever reason they have bad sonographic hygiene,

they know they don't do what they're supposed to do, they,

they start the study and there's legitimate reasons

why that's the case.

But what they can do is in the middleware there is an edit

function that allows them to,

after the fact, make sure

that the correct patient information is there.

So that would be, that would be like 99% of the time.

There is a scenario where either there's a, you know,

the patient is misidentified, so that would be,

you know, heaven forbid the patient has the wrong

MRN on or whoever was putting the information

in, did it incorrectly.

Or sometimes ultrasound machines, when they try

to query the work list, they fail

and they will just display the previous results.

So that occurs at, at times as well.

And in that scenario, I mean,

that can be a little bit challenging

because it's the person who did the study obviously needs

to recognize that there was an error in inputting the

patient information, right.

So that would be key number one.

And then number two is that they could then go in

and just the way that they altered the patient's information

with the time date stamp, they can do the same thing.

They can go in and make a change to that.

All of that has to be done

before a study is signed and sent to the EMR.

If a study is signed and sent to the EMR,

it's already in the EMR, you can't, I am not aware of a way

to retrieve that other than asking your, you know,

imaging systems department

to actually physically go in

and remove that errored, you know, that incorrect study.

- Yeah, I, I agree there's different solutions

for the different problems.

One a,

a good middle oil program will have a, an admin function

so that if it gets to a stage where

let's in in, in our scenario at a residency

where we have a resident that might assign the patient

to the wrong attending the admin function, if

that's identified, that can be rectified fairly quickly.

So there's a, a layers that

where the end user can fix the problem,

where if they have a supervising attending,

they can also address the problem.

And then ultimately your admin user has that ability

to go in and correct whether it's a study type

or more commonly a demographics.

So there is some, a,

a good system will have some backup built in so

that there's less of those studies associated

with a wrong patient or just a wrong attending physician.

- Yeah. To me that seems like an incredibly important

function of, of middlewares having the ability

to adjust some of those

details when you're doing an encounter based workflow and,

and, you know, while an order based workflow makes a lot

of sense for your stable patients,

where you're certain about what you're going to do next,

you know, the encounter based workflow is really a necessary

part of, of a lot of emergency medicine

and lots of other areas of the hospital.

So the ability to, we all know that mistakes happen,

unfortunately, and, and especially mistakes with data entry

for fast police clinicians, having the ability to go and

and rectify it before you send it

to the patient chart seems like a pretty important,

pretty important part of a middleware software.

What I'm wondering about the next steps is, is really

how has poca specific middleware affected

or enabled your sometimes older,

sometimes less tech savvy colleagues to save

or document focus studies.

Do you find that the middleware processes

and interface are easy enough for them

to effectively navigate?

- Yeah, this, John, do you want to address that trace?

- Yeah, I mean, I'm sure we're gonna come up

with very similar answers.

I mean, it's like anything,

your peak learning is at four years of age, you know,

and we haven't figured out a way to identify ED physicians

or, or those that are gonna be using the ultrasound probe

and get that neural network going.

So, you know, the, the,

but we've, even with folks

that have been fairly ingrained in their ways,

if you can make, if you have a solution

that doesn't interfere with their,

with their workflow entirely, doesn't bring on

an extra significant amount of work, they,

they realize the benefits.

So people are willing to invest that time.

They know that it involves, it, it, the end result is

better patient care, better communication

with downstream colleagues

and also better, better revenue stream,

more reliable revenue stream.

So the, it it, while there's a learning curve

with any system, a a good system will have minimal barriers

and can be picked up fairly readily and used.

I mean, for instance, w we, we had a, well,

we implemented our system, which we do use synchronicity.

When we implemented it, it was actually fairly,

I'd say within, certainly within the week,

people were very comfortable with it.

It, it just, for us it was fairly intuitive.

So again, each learner is different,

but once they recognize the, the value,

most people are willing to put the time in.

And really the, the time commitment is, is is not one of us.

- So as ultrasound spreads across medicine, you know,

talking about our, our colleagues, do you think, do you find

that some of your colleagues who perhaps do point

of care ultrasound within your department are using the

middleware to archive their studies on patients

that are still physically in the emergency department?

- Yeah, great question. So the que so

does contemporaneous documentation occur with patient care?

I think that's really the question you're asking.

So, you know, ideally yes, that's

where we want to be, right?

And so I think that this is a little of,

I mean there's a lot of factors that depend.

Do I document my, you know, my regular stuff

during patient encounters?

Like as I got off shift, I mean

we were getting nailed pretty heav heavily.

It's a little hard to document at the same time

contemporaneously,

but I think that it's important to have the ability to do

so for certain exams.

So for example, if I find someone

with a large pericardial effusion where they have evidence

of tamponade physiology, I'm gonna want to have

that in there as soon as I can so that the downstream

people, which really is the upstairs people, right?

Because in the ED everything flows downhill

and we're in the basement that floods

and you know, all the bad stuff.

So I want the people upstairs to be able to see what it is.

Or if I have a surgical consultant that, you know, I,

someone's got acute cholecystitis, they need to see it

and they're not gonna want to come down

and see it on the ultrasound machine.

They're gonna wanna see it the way

that they normally see their stuff, which is

by logging onto the EMR,

clicking on the patient's chart and seeing it there.

And so I would say that that's where it's really valuable

to document contemporaneously The other ways

that we document,

I don't think the ultrasound is gonna be a whole lot

different in that it's, it's dependent upon what's demanding

my time at the, at the current moment.

I will say that, you know, the, one of the things

that has helped more than anything is the barcode scanner.

That that barcode scanner, like you have

to identify the patient

and if either, either if you're using an encounter base

or a work or a order based

workflow, you still have to identify the patient.

And the only way to do that is either to type the MN

and search the work list

or to do an auto query of the work list.

If you don't have a work list,

still the barcode scanner can just simply read the number

and put it in the ID field.

And that has made a huge, I think a huge difference.

And if you do that right,

then doing the other documentation steps

are a lot easier, right?

Because then I don't have to go find it

altered all this other stuff.

So if I do it right up on the front end,

it's gonna make documentation easier to do

and more I'm more likely to do it.

- Yeah. And and the other thing which you may touch on in a

little while, the documentation itself a a good program will

allow you to, will be very customizable

and allow you to basically set up each,

each interpretation with majority being

negative findings.

So I mean, when I open up, let's just say an EFA exam,

it defaults in our shop, it's blunt trauma, it defaults

to blunt trauma and the findings are all negative

and really all I need to do is sign it off.

And so that takes care of the majority of your studies,

which tend, you know, at least for us, tend to be negative.

So just it speaks to making

that workflow a little bit easier.

And then it also allows that those results to be entered in

so that your surgical consultants

or whoever has that will have quicker access to being able

to view the images and view your interpretation.

So

- Yeah, so certainly sounds like having some pre-populated

billing sheets for our sort pre-populated reporting sheets,

we facilitate both consultant engagement by seeing what,

what they need to take action

or to not take action depending on what's appropriate.

And then may also kind of help a bit further down the line

with, with some billing issues.

Just wondering about actually if you have any consultants

who use the middleware, say if they're coming down

to provide an opinion on a patient, do you find that

that involves pocus?

Do you find that they actually engage

with the middleware and find it useful?

- So I'm not, I'm I'm sure that every other hospital that,

or every everyone

that's on this line has incredible relationship

with their surgical department who keeps up

with all the modern literature

and is a hundred percent supportive.

The emergency department, I mean that's,

that's the target audience that's tuned in today.

I'm sure that unli,

but we're an outlier so it, it, I I can't say

that the surgeons have, I mean, they know

what the machine looks like

and they know that we twi twiddle a few dials,

but we're slowly bringing them on board.

So no, they, they, we do provide education

'cause we're residency so the surgical residents get exposed

to it and some of them that, and, and they, they get it

and so they're able to

off service rotators are actually able

to pick up on it fairly quickly.

But yeah, it, it's a struggle for us.

Like I said, we we're, we're probably very atypical

and everybody else lives under a purple sky.

So that's, I don't know.

Rob, what's, what do you come up with?

- Yeah, great question. So I, I think that when I,

when I lived in Nashville, we were starting to see

that movement in particularly in the ICUs

because they were using the same work, you know,

of course we're, we were using the same workflow

product or middleware.

And so they had requirements, the, you know, the,

the fellows who were mainly interacting

with anyway had the product, they were using the product

and so they were more likely to look it, look it up.

I would say in, in the current, my current shop,

we are the only, there are select people in the ICU

that are using our, the, our workflow system,

but almost always,

they're not gonna look it up in the workflow system.

They're just going to engage the study in the place

that they would expect to see the study,

which is in the results section of the EMR.

So in our workflow in the way that we have Cerner

as our EMR, and so what happens in our workflow is that

once you complete the interpretation of your point

of car exam, then it goes both to the VNA

and it goes to the EMR.

So if I look in the results section, I see the report,

the point of Carol shown report,

and I see a hyperlink that will open up a VNA viewer

and allow me to look at the all the ultrasound images

that were associated with a study,

could I get a sneak peek behind the curtain

and see what's, you know,

see what's there without an worksheet being completed.

I can't, unless I'm another person in the emergency

department, like another emergency department user.

And in that case I could get a sneak peek behind the curtain

before that worksheet were was to be completed.

And so I think that, I mean there are, it is not infrequent

to admit people for, you know, we will do a DVT study

or pulmonary edema or bedside cardiac ultrasound,

and you'll see throughout the inpatient documentation that

that was, you know, they'll say, you know, pointing care,

ultrasound, cardiac study was rep, you know, was done

and was normal or reported a normal ejection fraction

or there was a pleural fusion seen on the point

of car ultrasound exam

and, you know, it's not, it's common just like anything

to see that trail repeated trail of documentation

for a significant finding that that had significant impact.

- But it's not copy and paste

- Never, it's never copy and paste.

It's never copy and paste doesn't get copied forward.

Well it seems like in our discussion, you know,

we've identified that there's a, a tremendous amount

of overlap between good clinical documentation

and then some education stuff.

And then within education we have educating students

and residents, we have maintenance of certification

for attendings, we have credentialing

for attending physicians and, and residents as well.

So just talking about some of the qa,

some of the QA stuff that we can do with, with middleware.

So do you perform QA at your institution?

It sounds like the answer is yes for both of you,

which is fantastic.

And then who do you do it for?

Do you do it for learners or all scans, all staff?

Do you pick a percentage? How do you go about using

middleware to properly QA your studies?

- I wanna see what Dr. Ferry says first.

- So we, we QA 100% of studies

that are submitted for qa.

So what, so the question is, is what gets submitted for qa?

So if it's a, if it's a, a non

ultrasound privileged

or credentialed person, then

they are, they're not gonna be able to send their study

to the EMR without sending it first to someone

who is credentialed or privileged to sign off on that.

So that's, that's done within the middle

where, not in the EMR.

And so all of those studies get routed for qa

and so they, you know, there's a button that says submit

for a qa so they know they're submitting it for QA as part

of their learning process for a, for a clinical study,

a hundred percent of studies go to the QA file as well.

They go, they go in a little bit of a different bucket.

So I can tell if it's an educational or a clinical bucket.

So I think that's important.

Do I want to do a hundred percent of clinical scan qa?

No, but currently I'm not able to dial that down

to be honest.

So I I think that's a good question.

I mean I, it, I, it depends.

I've been in other, when I was in Nashville, I I wanted

to a hundred percent review every study that was submitted.

There's, there were political

and other cultural reasons why I wanted to do that.

In my current environment, I don't feel like

that's necessary.

And I, you know, ASEP guidelines say

that at least you know more than 10% it should be,

it doesn't need to be everything.

It should be some things.

I would, I would say just as a, as another aside is that,

you know, as we, especially in the emergency department

and in other areas in the hospital use point of carolon more

and more and more, it's just part of our practice.

It's a part of what we do.

I don't think that we need to have exceptional

practices for them.

Do we do a hundred percent QA of every airway?

Do we do a hundred percent QA of every patient encounter?

Do we do a hundred percent QA of every, you know,

deep sedation?

No, we do, you know, we do a small percentage

and I think that that's what we should eventually strive

to do is to get to a place where, you know,

we're still doing QA for clinical exams,

but it doesn't have to be a hundred percent

because I'm not providing an overread.

Right. I'm just looking to see, yeah.

Was that study correct? Were there some flaws?

I just want to ensure that the quality of the product

that we're delivering as through ultrasound

through our department is, you know, is good.

- I'd like to say that we had a planned effort

and now we're exactly where Dr.

Ferry just described, where we're just selectively doing qa,

but it's in reality, it's a function of the, of the,

of everybody's workload.

And so the, all the residents study, of course, get attested

to the clinical ones, get attested to

by their supervising attendings

and the attendings doing standalone studies.

We really, it's more of a selective percentage.

So we identify percentage, we review them on a, on a,

on a regular basis

and we get feedback, you know, they, they do have

to get rec credentialed every two years, so they have

to maintain currency and they wanna know how they're doing.

And so, you know, we, we can identify areas where maybe some

of the, some of the technique has slipped

or maybe just core applications

where they're just not thinking about it.

So I'd say more, we're more along the line of,

of a closely guarded secret percentage of,

of studies that we qa.

- Sure thing. Yeah, a hundred percent would would keep both

if it's a full-time job for both of you.

That's for sure. And it would be for me as well on

that same vein though, also portable devices are just

incredibly convenient

and also the vein of many POCUS QA program

and POCUS directors experience.

How do you see them fitting in and

how do you use your middleware to pull some of those studies

that occur on ultra portable devices under the QA umbrella?

- Well, the easy thing for us is

that we currently don't have, in our department

that I see, we don't have any handhelds

or ultra portable devices yet on our system.

They are in the ho like within the health system,

there are those, but they're mainly

almost exclusively ICU hospitalist devices.

And so I don't oversee the ICU

or hospitalists areas use of ultrasound, so I'm not

really engaged in that space.

So there is the, you know, like from a technical standpoint,

we do it, but fortunately

we've not gone there in the department to do it.

So that's the e that that's an easy out.

- Okay, well we've opened Pandora's box

and so, so there's, there's the rest of the hospital,

which we know they're smuggling in their butt, their,

their handhelds and,

and that's really, unfortunately that's out of our control

because you know, obviously we would like somebody

to review those and that's on them.

Now within our department, we,

while we've remodeled we a little bit,

we did have a small provider triage space

where physically you could not fit in

a cart based ultrasound.

So we did buy three handhelds

and our middleware, again, we use synchronicity,

we were able to make it a pass through

so you can obtain images on your handheld

and it passes through there.

There's no, because they have their own proprietary

middleware solution, but it passes through there

and it goes on to synchronicity

and we can interpret it there.

So we have that ability, we use it occasionally, but

after the remodel we're, we're able

to use the cart based units consistently.

But it is nice to have that capacity

and the images, look, you can tell where they came from,

but you can, you interpret with the same standards

and the same worksheets

and they get same qa, so it, it's actually able to,

to utilize handhelds with without any

hiccup in the workflow.

- That sounds like an important,

an important development here

because clandestine scanning that occurs with handhelds is

that remains undocumented, you know,

is a pretty common thing I think amongst emergency medicine

and as you alluded to throughout the hospital.

So being able to use a middleware solution to pull all

of those scans into the QA bucket

and especially if they're actionable,

seems like a pretty important functionality

of poca specific middleware versus a traditional

PACS and radiology system.

And it's great to hear that, you know,

multiple manufacturers of devices can have this, this,

you know, essentially DICOM export that'll let you

take a look and put it in specific metalware.

And Rob, it sounds like you've, Dr.

Ferry's just hasn't opened the box yet, so he's a lucky guy.

So diving into some of the backend stuff, you know,

e EMRs are, are incredibly complicated.

They're so robust

and it sounds like the interaction between your middleware

and your EMR is really a vital part of your POCUS workflow.

So have you encountered any issues with,

and actually, sorry, Dr.

Ferry said he, his house, his shop used

Cerner, Dr.

Hippskin, what do you use?

- So we're, we're also a a, a Cerner shop as well too.

So yeah, I mean when you, when you mix Cerner

and anything, I think you can expect

at least initially some hiccups.

I'll, I'll give, I'm sure Rob's got some stories.

I know that when we first adopted it, the,

the hospital had failed to keep up with the,

with the internet service provider.

So we had a, a version that

after buying a ver buying contracting for synchronicity,

everything worked fine and then

because the hospital didn't keep up on their end, all

of a sudden the first day the browsers weren't working.

So we switched to another browser fairly rapidly

and that addressed that problem.

And so there's, there's always the, the unexpected,

but in reality now that it's mature at our program, the,

the, the workflow is, is universally understood.

And, and so getting it into first

of course recording your results in, in, in synchronicity

and then exporting it both into the EMR via the

updates, the, the diagnostic in the diagnostic session for C

and it first a,

after it first goes into the results review, which as Dr.

Ferry said, that it makes it available visual

for anybody downstream in the entire hospital.

And then we just pull it in into our EMR.

So, so they actually, it's

fairly seamless at this point, to be quite honest.

- Yeah, that seems like an important function,

just making sure that you know

that it's there and that it's pretty seamless.

You both alluded to creating ultrasound specific reports

and, and it sounds like there's a lot of overlap

with the ASAP pre-populated worksheets, you know,

for billing purposes, right?

So it sounds like you export the study to the EMR.

How do you find, does middleware actually help you build

these studies if there's a billing code

that's applicable and appropriate?

- Yeah, I mean that's the only way that we build studies.

So, you know, a long time ago, back when we walked

to school, both ways uphill in the snow,

we used to take images off the machine

through a thumb drive, burn them, you know,

put 'em on another desktop, burn them to a CD,

and then sit, you know, stack them in the coder's office

with a date, you know, like our date range.

So if we were audited that they would be able to find the,

you know, to find the study.

And so, you know, that's obviously different today.

And so we don't, you know, if we're gonna bill a study,

we, the coders know that there has to be an image file,

image file link associated with it.

If someone just documents fast exam

done, it's not sufficient.

Whereas in previous iterations, you know,

like in the olden days if we said fast exam done,

they just assumed that there was an image saved there,

there really wasn't a, a great way to validate

that there was an image saved.

But, so this, this ensures that we're

doing the right thing from a billing perspective.

But the middleware, I mean, I think the most powerful point

of the middleware is it allows that image that's associated

with the study to actually be seen.

Right? I mean, I think that we want to get to that space

where, you know, the, the surgeon can say, oh yeah,

that's acute cholecystitis,

or the, the cardiologist can say, oh yeah,

that's heart failure reduced ejection fraction,

or, you know, all these things, you know, down the line.

I think especially as point of carlstone grows,

it's important to see that there's a, an image

that's associated with that, with that study.

- Y yeah, as Dr.

Ferry said, you can't, you can't bill

unless it's in your middleware.

It just, if you, you set it up that way so

it meets the requirements in terms of what you need

to document and then the appropriate signature on the study

and then having it imported in the chart.

So once it makes it to the EMR, then all those,

the way it's set up, all those elements are, are are there

for the, for the coders, it's made a, a,

a significant impact to be able to decrease the number

of studies that lack those elements

by having a functional middleware, I mean, I mean,

no one really likes to share specific dollar amounts,

but I can tell you it's really resulted in a significant

increase in the amount of not only

professional charges that we collect,

but also we like to, to point out

to the hospital their technical fees.

And of course that's a,

that may be a topic you're bringing up in a while,

but that certainly gives you significant leverage

in today's day and age when everybody's kind of fighting

for the last shackle that fell on the ground.

I mean, it really helps to have a robust system allows you

to, to bill appropriately and then document fine areas.

We work with the hospitals revenue collection management

system and there was a stretch where they weren't

collecting fees for their pocus chest.

And so we found a six month period

where they hadn't dropped in any charges.

So we were able to, you know, get some of that back

or they were able to get some of that back

and then moving forward they captured all those charges.

So having a, a software, a middleware solution that you can

rely on and you can get good reports from,

makes a difference not only for your own practice,

but can definitely make a positive impact on

the facility that you're in.

- Yeah, so certainly working in Canada,

the dollar values are a little bit different.

And what ends up happening is with, with middleware is

that you have the ability to prove what you did.

And there are lots of papers out there, academic works

that suggest that you do better.

There's a lot, a lot of windfall for any ultrasound program

that, that build studies appropriately and then,

and a spot where they're renumerated

and especially for the hospital,

the technical fees are, are an important part.

And then the second thing is, even if you're in an area

or a place like where I, where currently

where there's no remuneration specifically for pocus,

it still lets you prove what you did

and when you can prove what you did, you can fight

for resources as well

and you can say, not just, we need this, but we need this

and here's why, and this is what we did.

And when you get some a little bit drop of drop of money,

you can say, here's what we did with it

and this is how we're gonna make it better.

And so it lets you kind of build that momentum too.

So having an appropriate middleware to, to build studies

or to at least demonstrate what you've done

with the information is an incredibly functional part of,

of POCUS specific middleware that would be more challenging

to capture in, in other realms.

Just talking about this then, did you find that

that a middleware solution

and suddenly you both use synchronicity, was was easy

to implement with your ITT?

- Yeah, I think, you know, our,

our experience was great.

I mean, I, I don't have any complaints about our

installation of the, of,

you know, of the middleware.

We were using a another program so we leveraged many

of the resources that,

and some of that infrastructure that had been built as we,

you know, moved from one to to another.

But I, but I, you know, I guess the question is,

is if I'm someone who's listening to this

and I don't even know how to go about doing this,

I think it's important to know that

it takes a significant amount of resources

and coordination from your IT

department to pull this off.

And so generally there's interfaces with your EMR,

there's gonna be interface with someone who interfaces

with the the VNA

or if you are gonna put it in a PAC system,

then there's interface with,

especially if you use an encounter base system like us,

you have to interface with orders

and doing, you know, having reflexive orders

that are generated.

So there's, there's generally a lot of things that,

you know, we don't understand from, from our end, from my,

you know, from my end it's like,

other people are doing this, why can't we do it?

Just go do it, right?

So we're a little bit ignorant about

what exactly needs to happen.

There's security aspects, I mean, there's a whole host

of things that have to be done.

And so I think this is where it's helpful to say, yeah,

a lot of people are doing this,

but it requires a significant amount of coordination.

And this is not new to it. They do this all the time.

They have projects, they have project managers

and pro they, they hire project managers

because project managers are able to, you know, coordinate

and know what the resources are

and know what the touch points are to,

to install a software system like this.

And so I think if, if I were out there

not having done this myself, I think this, it's important

to know that you're going to need the support of it

and it's gonna take some timing on their end

to coordinate the appropriate resources

for the implementation, even as much as, as six month runway

to like get it in the, you know, to put it in the,

the, the queue.

And then to get all of those things done.

I think, you know, we did this in COVID, so

that was particularly challenging,

but at the same time, it just takes some time, right?

And knowing that there's gonna be some lead time is,

I think, super helpful.

- Yeah, I, I think that's a, a great explanation.

It, it always takes, it takes more time than need to expect.

It takes de it takes the hospital willing

to commit those resources as they are trying to fix a number

of other issues at your site, likely.

I think this goes back to the prior question

where you show the financial value to the hospital

and that allows them to maybe prioritize this as a project.

It's really, you know, they understand the dollars

and so making sure that they, they understand the reimburse,

the potential reimbursement,

the reimbursement's being left on the table due to a lack

of a system or maybe a system that's not been kept up

to date or is not flexible to meet your needs.

You, if you can win that argument, then

that's your first step then yeah,

getting the is or resources.

But in terms of the two teams working together,

it was really talked a lot of the same language.

I listened in and understood about 15%

and I was happy when it was 15%.

So they, they understand the needs, the Cerner,

I should say synchronicity has now done this at a number

of sites they're very familiar with is needs

or is is intimately familiar with their hospital needs.

So I, I think our process was fairly smooth,

but it was also during COVID and took a little bit longer.

And I believe that now that the processes have been kind of

worked out that it should be a, a a a much smoother,

a smooth pathway and,

and really any facility, if they're,

they wanna do it, they can do it.

- So I'll say a little bit different in Canada that

dollars are or can be a little bit harder to come by.

We used actually a legal argument to build that case

initially was that this is an important part

of medical legal documentation, especially for some critical

and important interventions.

And then moved along to capture dollars

and then once, once we had the ability to capture all

of our studies, then we could start talking in dollars

and then that was a lot more the,

the hospital could really see its return on investment.

So we started off with a big stick

and then ended up turning that stick into a big carrot

and that's how we got the ball rolling.

But we're coming down to the end of our time, so

just recapping things here for a second.

So, you know, we, we identified over the course

of our discussion that there's a lot

of flexibility in middleware

and that it really helps you improve your documentation,

it helps you improve education programs,

it helps you do some, some research.

It helps you really speak the language

of the hospital as well.

And using that to, to either use to leverage dollars or,

or other arguments to get a POCUS program up running

and make it a lot more robust helps you be a lot more

confident in your, in your diagnoses

and it helps you really communicate

with services throughout the hospital.

So that flexibility really

and leveraging that flexibility really helps

and as a considerable return on investment for,

for all POCUS users in the emergency department and outside.

So we'll move here with our last few minutes

to some q and a.

And again, I just wanna thank Dr. Hippskin and Dr.

Ferry for providing their, providing their viewpoints,

their expertise, and

for chatting a lot about middleware today.

So thanks very much, gentlemen.

- Alright. As Dr. Bell said, it is time for the q and a.

So like I said at the top,

you can submit your questions at the q

and a box at the bottom or the side of your screen.

It looks like we have one ready already.

So guys,

can clinicians from various downstream departments access

the POCUS patient's results in the EMR without having

access to the middleware

- I know at our shop?

Yes. Is the, is the, is the quick answer.

It, it's integrated into Cerner.

There's a section where all the radiology findings are at

and we're right in there.

So it's really quite easy.

There's no, there's no learning, extra learning.

They just need to click on where it says POCUS

and they get the results.

- All right, well it looks like we've covered all the

questions we have for today.

So a big thank you to Dr. Colin Bell, Dr Rob Ferry, and Dr.

John Hippskin for taking the time

to put together an amazing presentation

and discussion for this webinar.

We really appreciate you guys sharing your

expertise with the audience.

And thank you everyone so much for joining us today

and we'll see you for the next one.

Watch a panel discussion among Point-of-Care ultrasound champions, sharing their experiences on the value of not only archiving, but fully leveraging the value of point-of-care ultrasound practice in the hospital environment.

What You'll Learn

  • Identify the difference between storing images in PACS and utilizing POCUS-specific software.
  • Understand how a POCUS archiving / connectivity program supports quality improvement and educational programs for more consistent and safer patient care.
  • Communicate the value of a POCUS archiving / connectivity program to hospital budget administrators.
  • Facilitate billing for appropriate POCUS scans and increase ROI.
Colin Bell
Moderator: Colin Bell, MD, FRCPC
Position: Clinical Assistant Professor, Emergency Physician Department of Emergency Medicine, University of Calgary Cumming School of Medicine & South Health Campus

Dr. Bell is an emergency physician in Calgary, Alberta, Canada. He is active nationally within the Canadian POCUS community and is currently the clinical practice lead for the CAEP Emergency Ultrasound Committee. Colin was previously the POCUS director for the Emergency Department at the Kingston Health Sciences Centre. He completed his POCUS Fellowship at the Denver Health Medical Centre in 2016. Colin is active as a POCUS researcher. His focus is POCUS education and automated technical skill assessment. He is a passionate advocate for image archiving.

Show more
John Hipskind
Presenter: John Hipskind, MD, FACEP
Position: Ultrasound GME Director, POCUS Emergency Department of Medicine, Kaweah Health

Dr. Hipskind is a board-certified emergency physician in Visalia, CA. He is active nationally within the POCUS community. He currently is assistant medical director of emergency ultrasound at Kaweah Health. He also is Kaweah Health’s EUFAC accredited emergency ultrasound fellowship director and its ACEP CUAP accredited graduate medical education ultrasound director. 

Dr. Hipskind did his emergency medicine residency at Cook County Hospital in Chicago in 1995 prior to the widespread use of POCUS. He became an early adapter using radiology leftovers, listened to US based podcasts as they became available, completed his POCUS fellowship through the Ultrasound Leadership Academy and is now Advanced Emergency Medicine Focus Practice Designated through ABEM. 

Dr. Hipskind is active as a POCUS educator. His focus is on optimizing end user workflow and in improving coding for billers and reimbursement for end users.

Show more
Robinson Ferre
Presenter: Robinson M. Ferre, MD, FACEP
Position: Chief, POCUS Division, Indiana University Health

Dr. Ferre graduated from the Medical College of Wisconsin and completed an emergency medicine residency at Maine Medical Center. Following residency, Dr. Ferre served 3 years on active duty for the United States Air Force as the Emergency Ultrasound Director for the SAUSHEC EM Residency program. After separating from the Air Force, he completed an Emergency Ultrasound Fellowship at Palmetto Health Richland in South Carolina. 

Dr. Ferre spent 9 years at Vanderbilt University Medical Center where he founded the Emergency Ultrasound Fellowship and the Emergency Ultrasound Division. He currently serves as the POCUS Division Chief in the Department of EM and is the program director for the Indiana University School of Medicine POCUS initiative. 

An avid teacher of POCUS, Dr. Ferre has trained thousands of students and physicians of all different specialties throughout the United States, Guyana, Nepal and Iraq.

Show more
Related

This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.