Thoughts Regarding the Future of Sonography…

SONOGRAPHERS’ COMMUNICATION THOUGHTS REGARDING THE FUTURE OF SONOGRAPHY. Dennis Carney, the former program director of echocardiography at Spokane Community College, recently queried a group of individuals regarding their thoughts on the future of echocardiography and the impact on sonographers. Dennis’ visionaries included (The) David Adams, Dennis Atherton, Todd Belcik, Patrick D. Coon, Sandra Hagen-Ansert, Kenneth Horton, Peg Knoll, Jane Marshall, Robert McDonald, Elizabeth McIlwain, Richie A. Palma, Rick Rigling, Brad Roberts, Marsha Roberts, RDCS, Alan D. Waggoner, and myself. Clearly, the group is well seasoned, diverse, and opinionated, which for an editorial is a good thing. However, keep in mind that the responses are predictions of what may come in the future based on current knowledge, and is by no way evidence based, as it has not yet occurred. Enjoy and my heartfelt thanks to all who participated! Sonographer shortage: There is NOT a sonographer shortage, but there is an experienced sonographer shortage. For clarification, just taking pictures for the past 5, 10, or 15 years does not qualify one as experienced, nor does graduating from a ‘‘program’’. However, due to the perceived notion of a sonographer shortage, there has been an increase in number of graduates, mostly from proprietary schools, who do not seek or meet CAAHEP accreditation. As a result, new grads are finding a saturated marketplace, and the need for sonographers seems to be at a plateau. Having too many new graduates has the potential to shift the balance of supply and demand. Fewer job opportunities result in unemployed sonographers and the possibility of decreased salary growth since managers/administrators may not need to compete for staff. As more physician practices merge with hospitals, there may be an increase in sonographer layoffs due to mergers and acquisitions. Healthcare reform: As a short-term result of healthcare reform, volume within the cardiovascular (CV) ultrasound lab may plateau, with projected volume growth lower than previous years (taking into consideration hand-held and plans that the Center for Medicare & Medicaid Services (CMS). Cardiac sonography will continue to be a stronghold in clinical care for cardiac patients, pre-surgical evaluations, and stress testing. Reimbursement: Sometimes it just seems we are rearranging the deck chairs on the Titanic when it comes to reimbursement. But the majority think reimbursement will drop and eventually the matrix will change significantly if CMS’s plan for Episode of Care payments comes to fruition. Efficiencies will be a major focus in the future. The cost/benefit ratio of providing a service will drive what is done because we won’t be able to afford the additional time for non-value added techniques. As a result, quality exams done on appropriately indicated cases will save us. The constant pressure to do more with less appears to be a common thread in the future; technology has the potential to aid in that endeavor. Appropriate Use Criteria (AUC): Appropriate Use Criteria (AUC) was once the responsibility of the ordering physician; now it’s becoming part of the cardiac sonographer’s role as well. In response to overutilization of diagnostic testing and specifically cardiovascular ultrasound, appropriate use criteria guidelines have been developed and published. The idea is for referring physicians to use the appropriate use guidelines as opposed to insurance providers mandating precertification. The ACC and the ASE are collaborating in an effort to craft a tool that utilizes an AUC algorithm to determine whether a test is appropriate. If cardiovascular tests are ordered appropriately, there will be a smaller volume of work and therefore a smaller workforce; prepare for it.

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Point of care ultrasound (hand-carried ultrasound): Initially, point of care ultrasound will increase our business in the same manner that cardiac CT increased catheterizations. However, once the basics are learned, it has the potential to be a very powerful tool in that less unnecessary studies will be ordered. In the clinic, small systems will be used as a ‘‘first look’’ screen and become part of the patient’s history; only pa- Marti L. McCulloch, tients for whom more testing is necessary BS, MBA, RDCS, FASE will be referred for a comprehensive study. This is likely to reduce the number of Doppler studies requested. The miniaturization of echo equipment will continue, with improved quality/functionality of the ‘‘hand-held’’ echo machines, to the extent that cordless probes will become a reality sooner rather than later. Quality CV ultrasound: CV ultrasound has great potential if done right; however, if CV ultrasound is done poorly, some other imaging modality will rule. Basically, whoever answers the clinical question in the best and most cost effective manner wins. Although the quality in ultrasound is a very pervasive concept, the majority think the minimum level of quality is established through registration/certification and lab accreditation. Several states already require accreditation for increased rates of reimbursement from private insurance companies, and it’s only a matter of time before lab accreditation is required for increased reimbursement on all Medicare patients. Collaborative teamwork, combined with reasonable workloads, will be needed to assure quality studies. We must maintain a high level of quality so other modalities don’t become the test of choice instead of CV ultrasound. Licensure and credentialing: We are on the doorstep of ‘‘formalizing’’ our profession through licensure, mandatory credentialing, and lab accreditation. The credentialing organizations are moving towards mandatory re-credentialing. The general consensus of the group is that licensure and credentialing is a good thing and will continue to spread. If you aren’t credentialed, you’d better get there. Licensure should bring higher standards to our profession and hopefully, more money. Currently, licensure is in effect with the passing of the bills in New Mexico and Oregon; the domino effect has already begun with other states following suit (West Virginia, Massachusetts). Growth in new technology: Several areas in research have been growing steadily in recent years and have gained interest of both NIH/FDA and industry. These include molecular imaging using contrast-enhanced ultrasound, sonothrombolysis, and gene/drug delivery. All three will require the sonographer to have additional biology in his or her background and/or the opportunity to learn such. We will not experience the growth of new technology like we have for the last 4-5 years (strain, speckle and 3D) but we will continue to find clear-cut clinical applications for these technologies that add value and efficiencies. Advanced Cardiovascular Sonographer (ACS): The group was all over the map regarding ACS, but a majority thought that as far as professional growth and development go, it is essential. Having a clinical ladder with at least 4 levels is important for growth and job satisfaction, and an advanced level assists in that and benefits the lab. Some were skeptical about the value of attaining the Advanced

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Cardiac Sonographer credential unless they can function fully independently, including preparing and signing final reports. However, once reimbursement changes and there is not a fee for service, the advanced sonographer may act as a physician extender to the degree of interpretation. A few noted sonographers are technical staff who perform tests, do measurements and even give preliminary reports; these are ACS responsibilities already performed by sonographers. Contrast echocardiography: Contrast echo for myocardial perfusion/viability will never replace nuclear imaging and its use for endocardial border definition has not grown to any extent over the years. It just takes too much effort to do, and having sonographers do injections is problematic for most labs. However, contrast has made it possible to image the technically difficult patient. Again, contrast echocardiography will win in comparison to other modalities provided you can get the sonographer to use it! Role in interventional echocardiography: Sonographers will be spending much more time in the interventional and electrophysiology (EP) labs. There will be more interconnection with interventional cardiologists and the volume will increase as more devices

are implanted, more percutaneous valves placed, and more robotic surgery is performed. Crosstraining and multitasking: Sonographers entering the profession would be prudent to learn cardiac and vascular imaging. Individuals who multitask and/or cross-train will be ideal. For example, a sonographer who starts an IV, monitors ECG stress, can perform cardiac MRI, and can interpret a preliminary report or a nurse who can do an echo, monitor sedation, and start an IV will be invaluable. The sonographer should continue to grow professionally by cross training as institutions try to minimize costs and maximize throughput. Again, thank you to everyone who assisted with the content, especially Dennis Carney! Keep in mind that the material needs to be taken in context of what will happen in the future, most notably what will happen with volumes; they will plateau initially with appropriateness and potentially increase with increasing elderly population and volume of insured patients. Visit the Sonographer pages at www.asecho.org to learn more about Sonographer of the Month, Muniza Yousuf of the Aga Khan University Hospital in Karachi, Pakistan.

VASCULAR COUNCIL COMMUNICATION IMPORTANT QUALITY INITIATIVES RELEVANT TO THE VASCULAR ULTRASOUND COMMUNITY

NEWLY PUBLISHED PVD PERFORMANCE MEASURES, CAROTID DISEASE PRACTICE GUIDELINES, AND AN ICAVL ANNOUNCEMENT REGARDING TECHNOLOGIST CREDENTIALING The second half of 2010 and first quarter of 2011 have been active in terms of intersocietal practice guidelines and performance measures focused on improving and standardizing the quality of care for patients with peripheral vascular disorders. Many of these publications have implications for non-invasive vascular testing and the ultrasound community. In addition, the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) made a major announcement regarding future requirements for certification of vascular technologists. A summary of these important developments follows: PAD Performance Measures.1 2010 Performance Measures for Adults with Peripheral Artery Disease (PAD) were published in November 2010, reflecting a joint effort of the American College of Cardiology (ACC), American Heart Association (AHA), American College of Radiology (ACR), the Society for Cardiac Angiography and Interventions (SCAI), the Society for Interventional Radiology (SIR), the Society for Vascular Medicine (SVM), the Society for Vascular Nursing (SVN), and the Society for Vascular Surgery (SVS).1 This document, which was published in print and online, defines seven evidence-based performance measures related to the care of patients with lower extremity PAD and abdominal aortic aneurysms. Performance measures related to vascular diagnostic testing include: (1) measurement of the anklebrachial index (ABI) in patients at risk for PAD (age $ 70 years, age 50–69 years with diabetes mellitus or significant tobacco history, or age $ 18 years with walking impairment, claudication, or non-healing wounds); (2) annual surveillance of lower extremity infrainguinal vein bypass grafts with ABI and duplex ultrasound; and (3) at least annual surveillance of asymptomatic abdominal aortic aneurysms between 4.0 and 5.4 centimeters in size. It is intended that these performance measures be incorporated into quality improvement initiatives related to the care of patients with peripheral vascular disorders. For the full text of the PAD performance measures, visit: http:// content.onlinejacc.org/cgi/reprint/56/25/2147.pdf

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Extracranial Carotid and Vertebral Artery Disease Guidelines.2 This much anticipated tome of intersocietal practice guidelines, the ASA/ACCF/AANN/ACR/ASNR/CNS/ SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients with Extracranial Carotid and Vertebral Artery Disease, has just been released on-line and simultaneously published in Circulation, Stroke, and JACC.2 This comprehensive document, which represents a collabo- Heather L. Gornik, ration of more than 10 professional vascular, MD, RVT, RPVI neuroscience, and imaging organizations, is a useful tool for any clinician who cares for patients with vascular disease or practices vascular imaging. Specific recommendations pertinent to vascular testing include the choice of vascular ultrasound for the initial evaluation of the asymptomatic patient with known or suspected carotid stenosis with the caveat that it is performed by a qualified technologist in a certified laboratory (Class I, level of evidence C). Duplex ultrasound is also recommended as an initial modality to evaluate the patient with focal neurological symptoms consistent with internal carotid artery stenosis (Class I, LOE C) and for surveillance of certain asymptomatic patients with > 50% internal carotid artery stenosis (Class IIa, LOE C). The guidelines recommend against carotid ultrasound screening for patients without risk factors for atherosclerosis or manifestations of carotid artery disease (Class III, LOE C), but does identify certain asymptomatic at-risk patients for whom screening carotid duplex ultrasound may be considered, including those with atherosclerosis in other vascular beds (e.g., lower extremity PAD) or multiple atherosclerotic risk factors (Class IIB, LOE C), and certain patients who are scheduled to undergo coronary artery bypass grafting (e.g., age

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