Anywhere, Anytime?

“I will go anywhere, provide it be forward.” – David Livingstone (1813-1873)

Since its introduction by Edler and Hertz in 1954 echocardiography has become an indispensable tool in clinical decision making. Numerous cardiology guidelines rely on echocardiographic findings and underline the importance of echocardiography as a simple, inexpensive, and easily accessible technique for cardiac imaging.

In the past, ultrasound machines used to be large and heavy. Therefore, their use at the bedside or elsewhere outside the echocardiography laboratory was inconvenient or impossible. The first portable echocardiography machines appeared around 30 years ago. However, these early portable devices were still heavy and had limited functionality and image quality. During the past decade, it has been possible to perform full-quality echocardiography exams using laptop-sized devices. Despite the initial enthusiasm of many clinicians to go mobile with these machines, most of the scanners finally ended up on carts, rendering them to regular lightweight ultrasound machines on wheels.

The recent introduction of handheld devices the size of a smartphone allows professionals to carry an ultrasound scanner like a stethoscope, and to use it conveniently anytime and anywhere during routine work in a clinical environment. It should be noted that none of the current products allows spectral Doppler measurements. Consequently, new terms, such as echo stethoscope have been proposed to suggest that handheld devices are not real ultrasound scanners and are of limited usage. However, several studies have already demonstrated their surprisingly good image quality and diagnostic value. Extrapolating the continuous development of technology, the implementation of spectral Doppler capabilities will be just a matter of time. Therefore, it appears censorious to regard echocardiographic examinations with handheld devices as less valid and inferior. In the hand of a trained cardiologist, many clinical questions can be solved on the spot and, in most cases, relevant cardiac disease can be excluded without doubt. No matter if we think about triaging patients in the emergency room, improving the diagnostic value of ward rounds, or extending physical examinations in the outpatient clinic or in ambulatory services; handheld scanners have the potential to change the way we will practice cardiology in the near future.

As with any other imaging technique, the diagnostic gain depends less on the machine rather than on the skills and expertise of the operator. This aspect is of particular relevance for mobile echocardiography. Handheld devices are relatively inexpensive and have the potential to become widely used—not only within, but also outside the cardiology services. This implies that more people with potentially less or no training in echocardiography might base clinical decisions on images that they are not properly trained to interpret. Besides the discreditation of echocardiography as a method, this development could become a danger for patients, which we have to avert.

One possible mechanism of averting is the restriction of reimbursement for examinations with handheld devices. This mechanism works best if a method is either time consuming or relies on expensive equipment. Given the low cost and time demand of an echocardiographic examination with a handheld device, however, restriction of reimbursement will have only minor effects. On the contrary, it may prevent the desirable implementation of a potentially beneficial technique in the clinical routine of cardiologists. Considering further the technical quality of current systems and anticipating future developments, such as the implementation of spectral Doppler capabilities, reimbursement distinctions based on the class of a machine appear less and less meaningful.

The preferred mechanism of regulation should better link reimbursement to the training and skills of the operator. This would imply that also a non-cardiologist has to prove knowledge and skills in echocardiography and that certain minimal standards of documentation have to be fulfilled. In its recent position paper, the European Association of Echocardiography comments on the current developments in the field of handheld devices and proposes standards in which the importance of training is emphasized. Consequently, efforts are made by the European Association of Echocardiography to also offer certified training. It can be assumed that comparable activities are planned in other countries and by other echocardiographic societies such as the American Society of Echocardiography.

The study of Choi et al in this issue of the Journal nicely demonstrates the possibilities of modern echocardiographic technology and sheds some light on potential consequences for cardiologic patient management, both in a state-of-the art hospital environment and in the mountains of Honduras. In their article, the authors describe that an individual with basic echocardiographic experience (level 1 training in echocardiography) used a contemporary pocket-sized ultrasound device during a humanitarian mission in the mountains of Honduras to augment physical examination. Images were transmitted from the field to expert echocardiographers located in Washington D.C. for remote interpretation on a PC workstation. After a minimum of four weeks after the initial reading, the same studies were read again using a dedicated smartphone application for medical imaging. Choi et al found an excellent agreement between the two readings. The authors conclude that remote expert echo interpretation can provide back-up support to point-of-care diagnosis by non-experts and that mobile-to-mobile consultation may improve access to accurate echo-interpretation by experienced cardiologists even in previously inaccessible locations.

It is one merit of this study that the authors demonstrate again the usefulness of pocket-size devices in a hostile environment in conjunction with a remote core-lab. This is in full concordance with several previous studies which have already demonstrated the clinical potential of handheld devices. We have to be aware, however, that the sensitivity of an examination in such a setting depends primarily on the skills and expertise of the operator to acquire the right information. The reader of a study cannot see more than what was imaged.

Secondly, the authors have demonstrated the feasibility of internet based diagnostic image data transfer. Being accustomed to being connected to the (western) world anywhere we go, this part of the study appears as a minor challenge and we may find it rather surprising that the majority of image data had to be couriered to a place with broadband internet connection because of insufficient local telephone networks.

The main focus of the study is, however, the supervision of echo examinations using a mobile phone application. Technically, this goes hardly beyond what any better smartphone can do nowadays; downloading and playing video files. The bigger question is if image size and quality are sufficient for diagnostic purposes. Image quality of the handheld device has been proven to be sufficient and so it can be expected, that a screen on a smartphone which has a comparable screen diagonal (both 3,5’’) but double the number of pixels compared to the handheld ultrasound device (320×480=153,600 vs. 240×320=76,800) should be at least equivalent and not worse.

The study also allows us to reflect about where technological development leads us. Not only that we can acquire echo data anywhere and anytime, but we can now also supervise echocardiography anywhere we go at any time. In that sense, echocardiography keeps pace with the omnipresent acceleration of our lives. But do we need that? Do we want that?

More and more often, people consider it mandatory to promptly react anytime the red inbox light on the smartphone starts to flash. Will we do that now with all incoming echo studies? Of course, there are emergency situations where such technology can save lives and, of course, there is certainly a place for it in sparsely populated areas or regions with underdeveloped infrastructure. However, in a developed western country, a smartphone based remote echo supervision may be interpreted as an exaggerated attempt to save costs if not just as a sign of bad organization. Echo is one of the most important imaging techniques in cardiology and therefore, we should make sure that expertise is locally available anywhere cardiology patients are managed. For the sake of their patients, cardiologists should insist that, as a standard of care, time and room is allocated for high quality echocardiography under optimized conditions whenever possible. “Anytime and anywhere” is part of the promise of modern technology, but what should guide us is to maximize the benefit for our patients.

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Jun 11, 2018 | Posted by in CARDIOLOGY | Comments Off on Anywhere, Anytime?

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