By Matt Skoufalos
When the latest and greatest technologies don’t solve all your problems on their own, what’s necessary to manage them becomes grounded in different kinds of decision-making.
Dr. Ryan Gibbons, an emergency medicine physician and associate professor at the Lewis Katz School of Medicine in the Temple University Health System of Philadelphia, Pennsylvania, learned first-hand how disruptive the scope of innovation can become when Temple concluded its 2021 whitecoat ceremony for new medical students with a show-stopping moment. At the direction of Katz School Interim Dean Dr. Amy J. Goldberg, all 220 students of the Class of 2025 reached underneath their seats, and pulled out a Butterfly iQ+ point-of-care ultrasound (POCUS) device. The gift, made possible by an alumni donation, put the technology in the hands of every incoming medical student for use throughout the next chapter of their education, and beyond.
Gibbons directs ultrasound in medical education and the emergency ultrasound fellowship at the Katz School of Medicine, as well as being the associate director of the hospital’s emergency ultrasound division. Not only had nothing like the Butterfly been available when he began his residency at Temple 10 years ago, but Gibbons described himself as among the least likely early adopters of any technology.
“People make fun of me for talking on my iPhone 4,” he said. “When I started my residency back in 2012, I had no idea what ultrasound was, and now it’s expanded across multiple specialties. But we’re supposed to be lifelong learners, and this is one of those examples where you’ve got to adapt to what’s happening.”
Completing a POCUS fellowship at Temple gave Gibbons a leg up on the ultrasound training that emergency room (ER) doctors typically might receive throughout the course of their education, and as he came to appreciate the value of ultrasound in practice, Gibbons became more outspoken in stumping for its broader adoption throughout the clinical and educational environments at Temple. The curriculum had been slowly building prior to the donation of the Butterfly devices, and the infusion of capital that spurred the purchase “kind of coincided at a perfect time when I was pushing to expand the curriculum,” he said.
“It really is a small world, POCUS, and it’s something at Temple that I wanted to contribute, and one of the main reasons I wanted to get this [program] up and running,” Gibbons said. “The technology really has changed the way we can practice medicine. Not only is it augmenting your physical exam, but it’s allowing you to narrow your differential diagnosis or potentially diagnose at the bedside. You can scan, interpret and make decisions in real time.”
That benefit is particularly trenchant in Gibbons’ work as an ER physician, a practice environment in which he might be the only doctor in-house under certain circumstances. Now, without any other emergency physician on call, or even in the absence of any radiologist or technician who can perform an ultrasound, his familiarity with POCUS has helped him deliver improved bedside care that also has benefited other specialties. He believes that by introducing the next generation of medical students to POCUS as early as possible in their schooling, it will cut down the knowledge gap that they might have to overcome later in their careers anyway.
“One of the biggest challenges of any new technology is whether people can adopt it, learn it and understand it,” Gibbons said. “The earlier you introduce it, the more easily people are going to adapt to what’s going on. We’re on our third year, and we’ll have 600 students with these in their hands. How do we develop a curriculum that can meet the needs of the students, and how do we train 200 students per class? That has been a big challenge to say the least.”
Another of the challenges to introducing this skill set to students, Gibbons said, is that they must use POCUS routinely to use it well, obtaining and reviewing images over and over again to hone their proficiency. Previous to acquiring the hand-held devices, the school had relied on a handful of cart-based traditional ultrasound devices that cost tens of thousands of dollars a piece and could only be used by one student at a time. The handheld roll-out has meant that Temple can expand and develop its ultrasound curriculum.
“That’s what’s going to be able to change people’s practices,” Gibbons said. “The biggest advantage of what we’ve been able to do is to improve the access our students have to ultrasound to learn it. When you have so many students trying to get their hands on a probe, it limits the time they have to use it. Now they can practice at home, they can practice with their friends, and they can bring it to the hospital in their clinical years.”
With more than 200 medical students per class now commanding POCUS technology at the point of care, that still doesn’t assure its smooth integration into the practice environment. Instead, it puts the students ahead of the majority of veteran physicians who aren’t very familiar with POCUS, its use, and its interpretation, which can be another integration challenge, Gibbons said.
“Most physicians are accustomed to ordering an ultrasound,” he said. “The patient goes down to the suite, someone performs the exam, someone interprets the exam, and then you get the answer. When you have 200-some students come into the hospital with only a handful of physicians who are familiar with POCUS, it does come with some issues. Are we going to let them practice on each patient? Are they making clinical decisions based on this? We’re trying to figure out the best way and the safest way for students to bring this technology to the bedside appropriately.”
Gibbons also said that he’s encountered some resistance from physicians who adhere to what he described as a more traditional mindset, and who were not eager to learn about the program. That underscored his observation that faculty support for the ultrasound program isn’t just a challenge from an educational perspective, but from the standpoint of building buy-in among faculty; finding those who are willing to be trained on the systems and become champions for the technology within the system. Most of the support he’s found has come from faculty who are giving their time freely, which isn’t guaranteed in all practice environments.
“You need a large cohort of other supportive faculty,” Gibbons said. “Some have practice with POCUS, and others are just learning it and willing to help out. Some people truly buy into lifelong learning, and sometimes they don’t. Whether it’s at an academic or a community hospital, you need someone who understands the benefit to doing this, and you need to start small. You’re going to meet resistance because there’s a lack of understanding, legacy issues with training, credentialing; there’s a lot of things that go on behind the scenes from a whole system-wide perspective. Start small, be patient and have an advocate.”
While Gibbons has the added responsibility of integrating POCUS into the clinical and academic environments at Temple, he remains free from being tasked with managing the back-end aspects of the technology. Those, however, are the specific challenges that Trent Conwell, IT director for Sentara Healthcare of Virginia Beach, Virginia, has been juggling since tackling the work of standardizing and storing reliable access to medical images at Sentara’s 13 hospitals across some 300 miles of Virginia and North Carolina.
“We didn’t feel as if we had a true standard, or that we could support it over a wide-area network with proper performance,” Conwell said. “Modality vendors’ file sizes just continue to grow and grow and grow. Now we’ve got a factor in here that is making us re-examine having these siloed data storage solutions. They’re just not cost-effective.”
Conwell also discovered the creeping challenges associated with integrating legacy PACS systems within a vendor-neutral archive (VNA). At one point, Sentara was trying unsuccessfully to tie together six different legacy PACS systems into a third-party VNA really well. After installing a Mach7 enterprise PACS system, however, the health network managed to resolve its system integration issues, but was left with new challenges — balancing increasing storage costs with high-performance demands — that required policy solutions as much as technological ones.
“Many organizations like mine are sitting here with studies that are 20 to 25 years old, and what’s the purpose of keeping those?” Conwell asked. “What are we doing with all these studies? Legal, financial, technology [departments] — they say ‘Get rid of it for performance, liability, or financial reasons.’ Clinical says, ‘Keep it all.’ In many organizations, clinical is winning out because they’re playing the patient safety or regulatory cards. So everybody gets confused by it, and when budget cycle comes around, they don’t have time to untangle it. We just budget more money for storage and go about our business.”
For as pleased as he was with the technical ability of the Mach7 to manage image life cycles, Conwell felt frustrated at having his hands tied by business rules that didn’t allow for his department to make the best use of its functionality, and in turn, save time, money and effort. Determining the relevance of which studies to preserve, for how long to preserve them and how to manage the costs of doing either became a challenge to be negotiated inter-departmentally.
“Organizations are dealing with performance issues because modalities are growing, solutions are growing, and vendors are designing tiered hardware and tiered storage, driving up the costs,” Conwell said. “So what can we do? Where do we see this going? If I could save $X million year-over-year in storage costs because I went from an average of 6.5 copies of studies to two, could I invest that into my network?”
“We did, and it’s been a one-time capital cost,” he said. “When you take a look at it over five years, the savings were still substantial. We could dump money into our network infrastructure and still have three years of storage savings on the outside. Let’s go ahead and cut our storage volume by somewhere between 40 and 50 percent. That’s just image life cycle management.”
Conwell said he’s been amazed to discover that all 13 hospitals can manage their digital image archives from one central database and provide appropriate performance at each by managing the archival issue and reinvesting in the network.
“The clinical side is physician-led, and that’s the way it should be,” he said. “I’m here as the IT director saying, ‘Once you figure out which way to go, I’m here to deliver it.’ ”
Finding a way to blend seamlessly the demands of cutting-edge and legacy imaging technologies may require some fundamental underlying work to create uniformity of experience throughout clinical environments, said Rekha Ranganathan, GE Healthcare interim chief digital officer, and senior vice president and general manager of imaging solutions.
“While everyone wants the hardware to last longer, they also want the functionality to be the latest and greatest,” Ranganathan said. “Your PC can be old, but all the applications have to be new. A lot of our customers have multiple CT, MRI, X-ray machines, and because of this drive to standardization, they want fleet management solutions – software management applications that have reduced variability between different systems.”
One aspect to the GE Healthcare approach to improving imaging operations is the Edison Imaging and Imaging Protocol Manager, a cloud-based solution for editing, monitoring, and managing imaging protocols, which are some of the most time-consuming tasks for technologists to get a handle on, specifically because they keep evolving. Edison offers physicians a chance to use the same protocols across all devices, while also updating and managing them with authorship so it’s known who made the changes.
Another solution, Digital Expert Access, enables senior technologists to see the consoles of their junior technologists, Ranganathan said, offering protocol guidance, and fielding questions across multiple sites remotely.
“We call it a remote collaboration tool; that’s been a big part of our fleet and workflow management,” Ranganathan said. “It increases the leverage of what a senior technologist can do at any point in time without having to be at a single location. They can counsel up to eight junior technologists at the same time.”
Additionally, Ranganathan said, the company is also working to increase the modularity and standardization of the devices it retails, the better to improve operational efficiency and integration.
“The number one topic we hear about from our customers, especially imaging, is operational efficiency, which has different flavors for different customers,” Ranganathan said. “A lot of the work that we do is really not about real-time stuff; however, if it is touching the raw scanner, and the raw data, making it vendor-neutral requires a lot of work.”
“I think we have a long way to go for the industry as a consortium to improve interoperability in a critical care or emergency room environment,” she said. “We do have partnerships to try to move the industry, but if we are all as an industry able to come up with the right standards, I think interoperability will come. Some of this is really about the industry coming together to move ahead.” •