The Role of POCUS Workflow
July 28, 2021
Medicine and technology are continuingly advancing, leading to improved care for patients. One especially bright spot in the current landscape is the development of point-of-care ultrasound (POCUS), a revolution in the medical imaging and diagnosis space.
What Is Point-of-Care Ultrasound?
Point-of-care ultrasound refers to the practice of a medical professional using ultrasound for diagnostic purposes wherever the patient is seeking treatment. It’s essentially a form of medical imaging that happens right at the patient’s bedside—or wherever their “point of care” might be.
For example, instead of sending a patient to the radiology suite for imaging or scheduling a separate imaging appointment, you may be able to diagnose that patient right where they are by using POCUS. This makes POCUS especially useful in nontraditional treatment facilities (like remote villages or pop-up medical tents) or on-the-go (like in an ambulance). Urgent care clinics are also finding POCUS to be an appealing tool, especially due to its lower cost and increased portability.
If time is of the essence, POCUS can provide more immediate results, versus waiting on imaging results to come back from radiology. In fact, one study on POCUS and diagnosing pericardial effusion found that the time-to-diagnosis with POCUS was 5.9 hours versus over 12 hours when other imaging modalities were used.
Another bonus is that POCUS allows physicians to look inside the human body without the risk of ionizing radiation that comes with X-rays and CT scans. POCUS is not meant to be a replacement for other imaging tools, but it is an excellent first step when determining what the next move should be (whether that be additional imaging or diagnosis and treatment).
What Can Point-Of-Care Ultrasound Be Used For? POCUS can be used to evaluate and diagnose a wide variety of medical conditions in different areas of the body, including:
- Pericardial Effusion
- Decreased Systolic Function
- Testicular and Gynecologic Conditions
- Undifferentiated Shock
- Cardiac Arrest
And these are just a few examples of the many diagnostic uses of POCUS. It can even be used for routine medical examination tasks, like finding the right vein to insert an IV. POCUS is also helpful for invasive ambulatory surgeries, as it increases the safety and efficacy of these surgeries that are otherwise performed blindly or using anatomical landmarks.
It is clear to us that ultrasound is the future—it is non-radiating and has no harmful side effects. We want to take the technology and put it in the palms of physicians. We also want to bring it down to the patient level. The beauty of having this window into the body is you can immediately see things.
Point-Of-Care Ultrasound Workflow
When it comes to radiology and imaging workflows, one of the biggest hurdles is that it’s a complex web. A familiar ultrasound workflow might look like this:
- The patient receives a physical examination, and the physician determines if an ultrasound exam is needed for further evaluation.
- The physician puts in a request for imaging, either at their location or another location.
- An administrator schedules the imaging session.
- The radiology department or facility prepares for the session.
- The patient returns at a later date for their image acquisition by an ultrasound technician.
- The radiologist reviews the image and patient data.
- The radiologist writes a report of their findings and sends it back to the referring physician and any other medical providers involved.
- An administrator schedules a follow-up appointment with the patient to discuss the results.
- The referring physician meets with the patient to discuss the results and next steps.
- The physician or billing staff member ensures proper documentation of all encounters and imaging for billing purposes.
You might already be able to see how POCUS can significantly shorten the timeline of this workflow. The above workflow may occur over several days, or possibly much longer, depending on scheduling, imaging issues, or any other problems that may arise in the gaps between steps. For instance, if the patient misses their separate imaging appointment or follow-up appointment, this results in lost time, money, and a longer path to diagnosis. One study even estimated that 67,000 no-shows can cost the healthcare system around $7 million. It’s inefficiencies and issues like these that call for a better solution.
With POCUS, it’s possible for all of these steps to occur in one day, and some steps are even eliminated. No more no-shows or waiting around for results, which will make patients happy and make medical work much more efficient. For example, our POCUS workflow, Exo Works™, wraps everything up in four steps:
- Scan with any DICOM-enabled ultrasound machine.
- Review and document findings within seconds after completing the scan.
- Automatically save imaging and reports to EMR and PACS for billing and storage.
- Securely distribute and access ultrasound exams through the cloud.
What Is a Point-Of-Care Ultrasound Case Example? To examine POCUS workflow benefits further, it can be helpful to look at case studies that demonstrate the differences in medical care when POCUS is used and when it’s not. For example, Dr. Robert Simard—an Emergency Physician at North York General Hospital and Sunnybrook Health Sciences Centre in Toronto—developed a series of case study videos to demonstrate point-of-care ultrasound benefits and efficacy. We will review his case study on small bowel obstructions (SBO) specifically.
To set the scene, this case study involved a 55-year-old male who presented at a hospital emergency department with:
- Abdominal distention
- Diffuse abdominal pain
He was given IV antiemetics for the vomiting and IV analgesics for the pain. They performed an X-ray—which the radiologist interpreted as normal—so the hospital sent him home.
Because the symptoms persisted, he returned to the emergency department the next day. The doctors ran through their usual questions to better evaluate the situation:
- Have you had a fever?
- Have you had any diarrhea?
- Have you had any shortness of breath?
- Have you had any testicle pain?
- Have you traveled in the past few months?
- Have you had any diet changes recently?
The patient responded “no” to all of these questions. When asked about prior surgeries, he mentioned he had his appendix removed about three years ago. During the physical examination, none of his vitals seemed abnormal. He rated his generalized abdominal tenderness at about a 3 or 4 out of 10. The physician noted no peritoneal findings, no flank pain, and he had a normal testicle exam.
After all that, most medical professionals would conjecture that this was SBO. Yet upon examining the X-ray from the day prior, the radiologist reported, “Nonspecific bowel gas pattern with gas seen throughout the colon, up to the rectum, a mild volume of fecal material. No evidence of obstruction or perforation.”
However, X-rays have proven to be not as effective as ultrasounds for diagnosing SBO. One study found that X-rays demonstrated 46.2% sensitivity with a specificity of 66.7% when diagnostic—but they were also non-diagnostic 36% of the time. Comparatively, POCUS demonstrated much higher sensitivity and specificity in different scenarios:
- For absent or decreased peristalsis, the emergency physicians evaluating the study participants noted that POCUS would show a back and forth movement of bowel contents within the bowel lumen (with a specificity of 97.7%).
- For dilated small bowel loops over 2.5 cm, the specificity was at 83.7%.
Both issues were noted during the male patient’s POCUS, removing the confusion of a seemingly normal X-ray and nailing down a timely diagnosis. Since he received his diagnosis during that same visit, doctors could quickly move on to a treatment plan to get this patient the relief he needed.
This is one of many examples of point-of-care ultrasound uses. So, what does this all mean for the workflow of imaging? With the real-time results and other benefits of POCUS, medical providers stand to get back significant time and energy from a streamlined workflow. And if costs and billing are factors stopping you from investing in this advantageous technology, they shouldn’t be. Let’s look at both issues, starting with costs.
How Much Does POCUS Cost?
Handheld POCUS systems are commercially available and only cost a fraction of the price of a traditional ultrasound system. If you’ve ever purchased ultrasound equipment, you may already know it can cost between $40,000 to $250,000 for low-end ultrasound systems, while high-end ultrasound machines can be priced around $1 million.This makes the low cost of a handheld ultrasound device quite appealing.
And on the patient side of things, the cost benefits are equally exciting. A study on the analysis of decision making and cost savings associated with POCUS found that POCUS use eliminated these costs on average for patients:
$1,134.31 of additional testing for privately insured patients;
$2,826.31 for out-of-network or uninsured patients; and
$181.63 for Center for Medicare and Medicaid Services patients. Can You Bill for a Point-Of-Care Ultrasound? Yes, you can bill for POCUS if you perform POCUS in your department, document the report, and store the images permanently. Ideal documentation will include:
The complaint or diagnosis along with the medical necessity or indication for the ultrasound
A description of your findings that relates to the initial reason for the ultrasound
Your official interpretation of the ultrasound
Comparisons to previous imaging, if available
It can get complicated tracking all of these requirements, leading to billing errors. Pat Palmer—founder and CEO of Medical Billing Advocates of America—reported that her organization would find errors on every three out of four medical bills they review. “We are seeing a lot of the error types escalating, especially in the hospital area. We have such a complex billing system, that it leaves so much room for errors to occur on medical bills,” stated Palmer.
Trying to stay up-to-date on the latest point-of-care ultrasound CPT codes, CMS guidelines for point-of-care ultrasound, and other ultrasound billing guidelines is a hassle. We understand how challenging this can be for medical professionals. Streamlining this whole process with a well-designed POCUS workflow—from the moment the patient seeks your care to the final diagnosis and treatment—can reduce this massive headache.
What Is the Best Point-Of-Care Ultrasound Workflow?
Check out Exo Works™, a one-stop-shop app that simplifies your POCUS workflow. You can evaluate, document, report, and submit for billing—all from the palm of your hand. Plus, we’ve incorporated a few other solutions that save additional headaches. With Exo Works, you can:
- Enter patients via barcode, worklist, or manually.
- Scan with any DICOM-enabled ultrasound machine.
- Tag exams as educational, if you’re still learning the ropes.
- Auto-save documents and findings to EMR and PACS for billing and storage.
- Distribute and access ultrasound exams through the cloud—securely.
- Easily and quickly assign ultrasound exams to yourself or another physician—no more ghost exams.
- Change an ultrasound exam with a few taps and split or merge exams when needed.
We strive to make the POCUS experience as easy as possible. With all the time and energy you will save, you can dedicate that time to what truly matters—your patients. Or maybe take a well-deserved nap.
Curious to see Exo Works in action? Book a demo with us today!