29 October 2009

Ultrasound in the ED

What Shari Welch Said.

Ultrasound is a neat toy, and I'm all about toys.  I found two opportunities to play with enhance patient care with our ultrasound today on my shift.  But it doesn't have the bang for the buck that the enthusiasts think it does.   It has very narrow, but real, utility, and does nothing to generate revenue.  It does in some cases enhance patient turnaround, and it certainly enhances patient satisfaction (they love cool toys as much as we do -- and extra face time with the doctor to boot!).  But that's a small return on a machine costing tens of thousands of dollars.

But what Dr Welch is griping about is not just the cost of the machine (after all, the hospital pays for that), but about the hassle and time required to generate a professional bill for ED ultrasounds.  The rules are fairly clear -- you need to archive the images, you need to generate a report comparable to that which a radiologist would have done (which is not to say that you need to perform a complete exam; the "limited" disclaimer will exempt you from the requirements for a complete exam, though you will bill out at a lower code as a result), and you need to perform regular Quality Assurance.  It's a big commitment, and if you are really going to comply with these rules it will take a lot of administrative time, and will certainly slow down a busy ER doc trying to, um, move the meat.  As an entrepreneur, I'm all about trying to maximize the income stream.   Is there potential revenue in ultrsound?  Yeah, sure, some.  Not a lot, and definitely less than the opportunity lost in the time required to realize that revenue.

I kinda hate to be a wet blanket on this point.  I mean, it's a gadget!  How can I *not* be insanely enthusiastic about it?  Turns out it's kinda like my old Palm Pilot (yes, I am old enough to remember when it was called the Pilot).  I was the early adopter, got one as soon as they hit the market.  Showed everyone how cool it was and evangelized about how it was going to change the way doctors interacted with patient data.  Slowly it started to get used less and less till it ended up in my desk drawer.  The ultrasound's not relegated to that ignominious fate and I doubt it will be.  But neither will it ever be one of those "I don't know how I ever got by without it" things.


  1. The bit from the other article that struck me was Dr. Welch's closing:

    I believe emergency medicine has misstepped in this regard. I envisioned that smart little sonosite eventually living in my pocket. I would carry it with me and use it to do procedures and answer those one sentence questions with mono-syllabic answers at 2 am. I would use it to diagnose fractures and abscesses and blood clots. Like Xray-vision- in- a -pocket, it would make me a better clinician. I never wanted to store images or generate bills. I never wanted to measure the common bile duct. I never wanted to be an Ultrasound Tech!

    Before I read that, I'd already been in mind of a friend's telling me years ago that the ER docs in Germany carried little pocket ultrasounds, and used them as needed to get useful and quick information. I'd been wondering whether perhaps the whole problem is that here you're having to bill, and there they don't, and that makes most of the difference re their utility.

    If the situation were more like Dr. Welch describes it had been a decade back, would you see the devices differently?

  2. Agreed

    Of late, I have kinda wondered about using sono to measure CVP for my goal directed therapy sepsis patients.

    There are a ton of these "grey zone" sepsis patients where I really wonder if the risk-benefit of placing a central line falls in favor of placement.

    The idea would obviously be to measure CVP using bedside sono and only if a patient's response was low after adequate fluid resuscitation measured by sono assessment of CVP would you move to a central line.

    Here they are asking us to save $ and they want a central line on all these patients?

    The indications around this issue are simply too vague as there are a lot of grey zone severe sepsis patients- especially this Swine Flu season.

  3. Mental exercise: think like a bank or like Google:

    Google: I've got this thingy and I've played around with it and I realize it can make my life easier, maybe even make me a little money.

    Bank: But I work in an environment that's rife with rigid process. The process is bigger than me, it is what it is, I may not like it but I understand why it is the way it is and it's the cost of doing business. So unless the thingy can play nice with process, sorry, no thingy.

    Google: Rigid process is rarely designed to make life easy on the participants. However, that shouldn't be a barrier to making good things happen, especially when we can make a little money.

    Bank: Agreed.

    Google: Great - we've found some common ground. How do we hack thingy to make it play well with process? How do we eliminate manual action - process friction - so the data coming out of thingy is accurately attributed to a patient and a caregiver, reliably and securely transmitted and stored, and easily massaged into whatever form process wants to see at the end of the day? Does thingy need changing? How much is it worth to us to work with thingy vendor to get something that plays well with process? And how do we keep this from turning into a bloated IT project or committee-driven death march? And should we make this work, how do we avoid repeating all this effort the next time someone discovers a new thingy?

    Powers-That-Be: All very interesting questions. Perhaps you could get pry your pasty, chubby computer geek friends away from World of Warcraft long enough to hash something out. In the meantime, I'll be in the vault rolling naked in a pile of benjamins while outsourced monkeys create more process on secondhand Underwoods. Good day, gentlemen! Smithers! Fetch me a Fresca, stat!

  4. In my ED we've found the bedside US more useful for quick help with a dx in an unstable patient like ruptured aneurysms or ruptured ectopics than for replacing "real" ultrasounds. Its also great for finding the fetal pulse in the early pregnancy that you can't find with a doppler.

  5. I would like to see ultrasound used on more patients needing imaging in the ED.

    I presented to the ED with appendicitis as a 24-year-old who had previously had imaging done the same day at an outpatient CT scanner (I was told by my PCP that it would bill my insurance at a lower rate, and cost was a concern).

    Although I suggested an abdominal ultrasound, they did a CT scan anyway. The surgery resulted in severe post-operative complications (MRSA, bowel obstructions, two metal objects removed from my abdomen in a 'revision surgery' a year later). In the course of the drama, I had about a dozen CT scans. I would have liked to have had fewer, due to concern about the ionizing radiation.

    I believe that the reason I had so many CT scans was because they were easier to bill. Please advocate for making ultrasound easier to bill at a comparable level.


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