Dr. Spencer cautioned that ultrasound shouldn’t replace echocardiograms or other tools. “So no one is proposing that this would replace a full exam,” he says. “What we’re hoping is that this would detect things that have gone missing or would help ask very specific questions at the bedside.” His studies suggest the approach works well as long as the questions are simple: “Is there fluid or not? Is the heart good or bad?’ But not: ‘Is there an infection?’”
Beyond cardiology and the emergency room, Dr. Spencer says ultrasound has obvious imaging uses in the ICU. The dichotomy, he says, is that imaging intensive care patients can be especially difficult due to their edema, wounds, and lack of mobility. “That area has not blossomed as well as it could have,” he says.
Even so, the burgeoning number of applications for ultrasound “really has huge potential for good,” says Harvey Nisenbaum, MD, an associate professor of radiology at the University of Pennsylvania School of Medicine and president-elect of the American Institute of Ultrasound in Medicine (AIUM). “But the problem is that it’s an art form in the sense that it’s not automated.” No two ultrasound images will be identical, for example, because each depends upon the probe’s precise location. The key, Dr. Nisenbaum says, is proper training under agreed-upon guidelines, followed by continuing education and the maintenance of a hospitalist’s competency.
The AIUM, Nisenbaum says, is working to develop standard credentialing criteria for a range of ultrasound applications to help unify what has been a patchwork approach. Another limitation, he says, has been the lack of Food and Drug Administration (FDA) approval for ultrasound contrast agents Optison and Definity for noncardiac applications. Several deaths have been linked to the use of the intravenous agents in the sickest patients.
The institute is working with the FDA on trying to get the reagents approved for broader use, as they are in other countries. Nisenbaum cautioned the process likely will take a while. Once approved, getting a reimbursement code established for insurance purposes could take even longer.
A further obstacle, according to Dr. Spencer, is the lack of resolution surrounding medical legal issues. “Are we going to agree that this is like a physical examination?” he asks. “It’s unclear whether the medical legal community is going to accept that with ultrasound,” he says.
For cardiology applications, at least, he wonders if the push for reimbursement is such a good thing. “General internists are under incredible pressure [for billing],” he says. “They’re in a really tough spot, and so there would be enormous pressure to get reimbursed for every ultrasound.” As it is, he says, Medicare is targeting echocardiogram as an overutilized reimbursement item. “I hope the reason we’re using this is because we’re examining the patients anyway and this would allow us to find things that we might have missed,” he says. “It’s a better way of examining people, not a new technique for generating revenues. I think that would be a disaster.”
Jeffrey Wiese, MD, SHM board member and associate dean of graduate medical education at Tulane University School of Medicine’s Section of General Internal Medicine and Geriatrics in New Orleans, began putting ultrasound in the hands of his hospitalists and residents in 2007. It’s the “100% right thing to do,” he advises hospitalist groups. “It can be a meaningful way of improving safety. I hope that everyody would move that way.”
Dr. Wiese says residents began using ultrasound more and more for extra visualization during procedures.
“The reason we got into this was straightaway safety, independent of [Centers for Medicare and Medicaid Services] codes and billing—particularly regarding thoracentesis and internal lines,’’ he says. His hospitalists use SonaSite’s MicroMaxx system, “which was a key piece in the way of being able to bill. For all CMT just like endoscopy and bronchoscopy, you have to provide images of the procedure to prove you did it. With the MicroMaxx machine, it allows you to insert a USB and pull down images, take them to a print machine, print them out, and put them in a chart.”