In this Editors’ Page , I would like to share several experiences that I had quite recently, during the American Society of Echocardiography (ASE) Annual Scientific Sessions (held earlier this year in San Diego). These re-emphasized to me that in 2010, the field of echocardiography has perhaps never had more exciting opportunities, and more threatening challenges, than it does today.

One of the highlights of each year’s ASE Annual Scientific Sessions is the Edler Lecture. Named for Inge Edler, MD, who first used cardiovascular ultrasound as a clinical tool, the ASE Edler Lecture is customarily given by an ASE Past-President. The 2010 Edler Lecture was delivered skillfully by my good friend William A. Zoghbi, MD, FASE, who served ably as ASE President from June 2008– June 2009. Dr. Zoghbi presented a very thoughtful and forward-looking talk entitled “Echocardiography: A 2020 Vision”. He began by emphasizing that the history of echocardiography has been a success story of “sustained innovation”, and then reviewed the evolution of echocardiographic techniques over the past 60 years, starting with A-mode and later M-mode echocardiography and progressing to encompass an array of related modalities including two-dimensional (2D), spectral and color Doppler, transesophageal, contrast, tissue Doppler, real-time three-dimensional (3D) transthoracic and transesophageal, speckle tracking, and handheld echocardiography. Dr. Zoghbi kindly gave me permission to include in this column one of his slides ( Figure 1 ), which illustrates the remarkable history of innovation in echocardiography. This family of related techniques provides a powerful, painless means to diagnose, document the severity of, and evaluate the response to treatment of virtually every cardiovascular disease. Moreover, unlike many competing diagnostic imaging modalities, echocardiography can be performed at the point of patient care, whether in the echocardiography laboratory, the office or outpatient clinic, the intensive care unit or operating room or emergency room. Other diagnostic techniques may be very important in patients with known or suspected heart disease, but in my opinion none is as versatile and as widely applicable in 2010 as the family of techniques that falls under the echocardiography “umbrella”.

Evolution of Echocardiographic Techniques, 1950’s – 2010. The time points are approximate. Illustration courtesy of William A. Zoghbi MD, FASE.

In his lecture, Dr. Zoghbi went on to discuss his vision of how echocardiography might be practiced in the year 2020. He showed an example of a handheld “omniscope” (about the size of a modern smartphone) that would be used at the bedside or in the clinic, during the patient encounter, as part of the cardiovascular examination. Using a wireless imaging transducer, the examiner would use this device to perform, view, and store a set of ultrasound images, making diagnosis and triage rapid and efficient. As a wireless device, the omniscope could provide the examiner not only with the means to examine the heart and great vessels, but also the ability to view other diagnostic data (including relevant records, an electrocardiogram, and other images) at the point of patient care. This would make the patient encounter far more efficient for both caregiver and patient, help the caregiver select and order other services or procedures that might be needed, avoid redundant diagnostic testing, and allow institution of appropriate therapy sooner and perhaps more effectively. For someone whose career in cardiology has depended on listening carefully to heart sounds, formulating a diagnostic impression, ordering appropriate diagnostic tests to refine my understanding, and treating accordingly, I find the potential to accomplish all of this during the initial patient encounter an extremely appealing idea. In Dr. Zoghbi’s view, the “name of the game” in 2020 for those who practice cardiovascular medicine will involve making accurate diagnoses, starting proper treatment as early as possible, and doing so in a highly efficient manner that will best use available health care resources.

Which brings me to another series of experiences. In talking with colleagues from across the country and around the globe, I was reminded that in 2010, most of us practice under increasing pressure. As I am sure all readers know, reimbursement for echocardiography services (and almost every other diagnostic procedure) has gone steadily downward over the past few years. I do not see reasons to believe that this trend is going to be reversed. Rather, given the realities that the United States has a serious budget deficit (of course, the US is not unique in this regard), that the percentage of gross domestic product (a measure of the “size” of the national economy) spent on health care is presently higher than in any other country, and that the US population is growing in patient numbers, average age, and waist circumference, it is inconceivable to me that the next few years will be anything other than “tough times” for those who like the status quo.

Some colleagues with whom I talked told me that their institutions are having difficulty in keeping up with innovations in echocardiographic technology, and I am sympathetic. In an era of declining reimbursement, some echocardiographic practices appear to be taking one of two approaches, and sometimes both: (1) “making do” with existing equipment and deferring upgrades or purchases of newer technology, and (2) doing studies as “efficiently” as possible. Sometimes, “efficiently” is a euphemism for doing the minimum needed. As I have heard it discussed, apparently some echo laboratories and practices are using older echocardiographic instruments that do not support newer technologies such as speckle tracking strain imaging or real-time 3D transthoracic or transesophageal echo. In what I will term the “bare bones” approach, an echocardiogram to “assess left ventricular (LV) function” involves 2D echo imaging and measurement of LV ejection fraction (EF), or perhaps only an “eyeball” assessment. Simple dimensions are used to define LV and LA size. Evaluating “LV function” does not include tissue Doppler velocity measurements, or LV longitudinal strain, or detailed assessment of diastolic function. Valvular regurgitant severity is judged primarily by qualitative assessment of color Doppler images.

I admit that a skilled examiner can derive clinically useful information from such “basic” data. Working in this manner may allow a cardiac sonographer to record, and an echocardiographer to interpret, more studies in a day, if the goal is to do as many studies as possible in a given period of time in order to adapt to declining reimbursement. I do follow the logic, but the problem with this approach to being “time-efficient” is that it does not look at the big picture. For example, let’s consider an imaginary patient with hypertension, dyspnea, and declining exercise tolerance, in whom a “bare bones” 2D echo shows normal LV diastolic dimension, normal wall motion, and a visually estimated EF of 60%. The clinician might next send the patient for a stress test to evaluate for inducible ischemia as the cause of symptoms, or for a coronary angiogram. If these tests were negative, the patient might wind up having another echocardiogram, perhaps at another institution, specifically to investigate diastolic function. Let’s imagine that this demonstrated pseudonormal LV filling and a large indexed LA maximal volume, leading the treating physician to uptitrate blood pressure medications and perhaps add a diuretic. One could argue that if the initial study had been more thorough, the patient might have been able to avoid additional testing, and needed therapy might have been instituted sooner.

It is also important to realize that while many practitioners have become used to “fee for service” medicine, in which reimbursement is linked to volumes of services, the times are changing. It is fair to note that if you go to the barbershop, you are likely to get a hair cut whether you need one or not, since that’s what barbers do— they cut hair! Medical economists suggest that when doctors are paid based on the services they provide, they sometimes may be tempted to provide services that might not really be necessary. Pundits have observed that the most costly piece of medical equipment is the doctor’s pen (this is being supplanted by the keyboard or mouse or PDA), which he or she uses to order tests and treatments. Increasingly, those who pay for health care insist that a fundamental change in the basis for reimbursement is badly needed. In the future, instead of being paid for the quantity of care (or number of tests) they provide, physicians and other caregivers are likely to be paid for the quality and efficiency of care they provide. Efficient delivery of high quality care will (and should) become a priority.

To me, an additional concern is that using only older “tried and true” technology is absolutely the antithesis of the exciting opportunities offered by the array of diagnostic tools available to the echocardiographer, as Dr. Zoghbi so clearly demonstrated. If echocardiographers are to stand still, depend on standard 2D echo imaging using equipment produced a decade ago and not upgraded since, perform “ejectionfractionograms”, focus primarily on the left ventricle and simply “eyeball” the other chambers, and avoid new methods such as strain imaging and contrast echo because they are perceived as “a waste of time”, then I fear that echocardiography will be passed by. As the dinosaurs illustrated, we need to adapt and continue to evolve, or face the consequences.

The opportunities to use echocardiography in a more sophisticated and more effective manner are exciting. However, these opportunities come with challenges. We need to dedicate time to learn to use new technologies properly and to incorporate them efficiently into our practices, so that each patient gets the right test at the right time. We need to choose wisely when to perform targeted studies and when to perform comprehensive examinations. Echocardiographers, cardiac sonographers, and health care professionals will also need to find ways to afford to make use of ongoing improvements in technology, and to avoid stifling innovation and improvement. I worry that if clinicians do not use, or want to use, new techniques and equipment, then engineers will have little incentive to develop cutting edge diagnostic tools, manufacturers will have little reason to make them, and ultimately our patients will be deprived of the benefit of them. Some day I will be a consumer of health care, and not just a provider. When I need an echocardiogram, I want it to be done carefully and expertly, and I don’t care how long it takes to do it “right”. I’d like to avoid additional tests that might not be needed, and I want to be started on effective therapy as soon as the right diagnosis and treatment plan can be developed. For personal as well as professional reasons, I hope that the echocardiography community can continue to support ongoing innovations with optimism and enthusiasm.

While I don’t know all the answers, the questions are certainly worth restating. How will we adapt to the changing reimbursement landscape? Do our expectations need adjustment? What are the most effective ways to utilize resources? How can we afford to learn and to implement new and improved techniques? How can we afford not to? My own 20:20 vision may now depend on reading glasses, but it is quite clear to me that important questions need to be resolved so that Dr. Zoghbi’s 2020 vision may become a reality.

As always, if you have comments or suggestions, I can be reached at jaseeditor@asecho.org .