One of the greatest mandates for all aspects of healthcare in 2003 is the unceasing pursuit of quality. As healthcare providers first and foremost, echocardiographers know that quality impacts everything they do, every day. Their challenge as practitioners, and the American Society of Echocardiography’s (ASE’s) challenge as a professional society, is to continuously improve the quality of the performance and interpretation of echocardiography. To this end, the ASE is a founding member of the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL), which seeks to set and maintain basic standards of care and practice. Nearly half of the ASE’s members either work in ICAEL-approved laboratories or in those with applications in progress.
While the echocardiography laboratory is certainly the most critically important locale for ensuring quality, another essential component lies outside the echocardiography laboratory. Better understanding of the appropriate roles and benefits of echocardiography and its impact on health-related outcomes is needed. This includes appropriate test ordering by the referring physician and proper interpretation and application of the information gained from this diagnostic imaging study.
Perhaps related to the growing recognition of the need for quality standards, all healthcare providers are increasingly accountable for their performance. The Institute of Medicine’s (IOM’s) 2000 study on medical errors has brought great pressure to bear, which is manifest, in part, in the form of performance measures, which will be with us increasingly in the future. ASE will continue to set standards and encourage quality improvement in this and other ways and has been instrumental in the development of physician examinations that certify competence in echocardiography. The National Board of Echocardiography (NBE) offers the Examination of Special Competence in Adult Echocardiography (ASCeXAM) and the Examination of Special Competence in Perioperative Transesophageal Echocardiography (PTeXAM) developed in conjunction with the Society of Cardiovascular Anesthesiologists (SCA). A new membership category for physicians and sonographers was launched in 2002 – Fellowship in the American Society of Echocardiography (FASE) is a single credential, combining test performance, years of professional achievement and recognition by one’s peers.
It is impossible to discuss quality without emphasising ‘people’. The proper performance of an echocardiogram takes the contributions of a variety of individuals to provide the right care at the right time. The ordering physician begins the process by selecting patients who will benefit from echocardiography. Subsequent steps involve a scheduling secretary, a sonographer to acquire images, perhaps a nurse to start an intravenous line and give a contrast agent, a physician to interpret them, another secretary to type the report and, finally, back to the referring physician who will put the findings to use at the patient’s bedside. A properly performed echocardiogram really does require a team of individuals, each with their own unique contribution and area of responsibility. The actions of each are critical to achieving the goal of quality.
Bearing in mind the importance of the echocardiography laboratory team in 2003, strong evidence suggests that the size of the current echocardiography workforce is simply not up to the task of meeting current patients’ needs for echocardiograms. Shortages of sonographers and cardiologists are on the increase, with fewer individuals entering the workforce than are leaving it. The majority of laboratories have either a sonographer vacancy or are making use of temporary services. The average daily workload is increasing, with the majority of laboratories expecting an average of 11 or more echocardiograms to be performed by each sonographer, each day.1 The same pressures exist on the physician side. The average cardiologist’s workload has increased dramatically from 64 hours a week in 1998 to 67 hours a week in 2001.2 These are major issues for the world of diagnostic ultrasound and need to be addressed at a national level.
Exacerbating this increasing workforce shortage is a profound shift in the demographics of the American population. As baby boomers age, as the prevalence of metabolic diseases such as diabetes and obesity grows and as a growing number of patients with heart disease survive and require further medical care, the demand for echocardiograms will dramatically increase. With personnel shortages already being faced in 2003, it is difficult to imagine how the echocardiography workforce will function in five, 10 or 20 years.
In addition to its size, another challenging aspect of the echocardiography workforce is diversity and identifying who currently is and who will be echocardiogram users in the future. While those interpreting echocardiograms are largely cardiologists, the advent of transoesophageal echocardiography and its application in the operating room in the early 1990s created a whole new spectrum of users – anaesthesiologists and cardiothoracic surgeons.
With the recent introduction of small, light and relatively inexpensive hand-held echocardiography machines, increasing numbers of accident and emergency unit and general care physicians have become users. If hand-held echocardiography becomes a part of the physical examination, as a kind of ‘electronic stethoscope’, it is possible that all physicians, in every speciality, will become ‘echocardiographers’. Without knowing who the next echocardiogram user will be, it is difficult to predict the impact of echocardiography’s new, increased portability on clinical care or know the financial and regulatory ramifications. It remains to be seen whether hand-held echocardiography will supplant complete echocardiograph/Doppler examinations, thereby eliminating the role of the hospitalbased echocardiography laboratory, whether it will be a part of the physical examination or simply turn out to be just another interesting gadget.
The world of echocardiography has seen tremendous technological innovation in the 50 years since the first human cardiac ultrasound was recorded in Sweden in 1953. A-mode echocardiography has advanced to M-mode echocardiography to two-dimensional echocardiography, and Doppler echocardiography, transoesophageal echocardiography and stress echocardiography have been added. The list is long and each improvement has brought important advances in patient care. Most important for the future wellbeing of echocardiography, new advancements continue at a rapid rate.
Realtime three-dimensional echocardiography has recently been introduced commercially. This, in addition to the application of new software to quantify subtle, previously unmeasurable aspects of cardiac function, such as diastology and myocardial strain, promises to enhance the diagnostic accuracy of echocardiography. As with most cardiovascular practice, echocardiographers embrace new technology enthusiastically; time will tell what exact role new equipment and new techniques will play in the future of cardiovascular medicine.
One area that is certain to grow is that of vascular ultrasound. Echocardiography is increasingly not just about the heart and, for 69% of ASE members, the echocardiography laboratory is the primary location for vascular ultrasound. More and more attention is being directed to the entire vasculature as cardiologists include vascular medicine and vascular intervention, and now vascular diagnostics, in their scope of practice.
Other advances in echocardiography will continue to spread its use even more widely through the cardiovascular community. The advent of intracardiac echocardiography using catheter-mounted ultrasound probes has made echocardiography a mandatory tool in the electrophysiology laboratory (for transseptal puncture and atrial fibrillation ablation) and in the interventional laboratory (for placement of septal closure devices and balloon valvuloplasty). The development of high-frequency, short focus probes has enabled diagnostic quality images of small rodents, such as transgenic mice. Echocardiography is now a ubiquitous tool in the academic and commercial molecular cardiology laboratory.
Echocardiography has embraced the digital revolution, with most ASE members using digital image storage for a majority of patient studies. Increasingly, echocardiographers are envisioning true information systems and not just a digital archive. Such global systems would enhance the echocardiography laboratory’s operations by automatic or computerised order entry, digital online reporting and a seamless flow of information between the echocardiography laboratory and the enterprise hospital information system or electronic medical record. However, healthcare is notoriously reluctant to invest in information systems and the cost of digital archiving and retrieval systems is often unacceptable to financially challenged medical institutions. While the concept of digital echocardiography may be very simple to understand, we are still years from the widespread fulfilment of the vision of truly uniting the entire cardiovascular enterprise in a plug-and-play fashion. The ASE is partnering with Integrating the Healthcare Enterprise and the American College of Cardiology (ACC) to make this dream a reality.
Future Directions and Challenges
Current and future challenges to echocardiography lie in many areas; closest to home perhaps is competition from the medical imaging field. The clinic and the marketplace are increasingly crowded with new and improved technologies. Nuclear perfusion imaging used to be the only competition for echocardiography. Now, magnetic resonance imaging and multi-slice computerised tomography scanning are providing high-quality images and claiming superior diagnostic power. It is not yet known how these modalities will impact cardiovascular patient care, so it is impossible to determine how they will impact the market for echocardiography, and whether the increasing use of these far more expensive examinations will reduce or increase the value of echocardiography.
Multiple changes in the medical imaging industry further complicate prognostication. Whereas the dominant manufacturers were once small companies devoted to echocardiography, vendors are now multimodality, multinational corporations within which ultrasound imaging is merely an unexpected and unusual condition that is probably temporary.
It is impossible to consider the future of any aspect of the medical world without considering legislative and regulatory issues. Declining reimbursement coupled with increasing malpractice insurance premium costs and other operating costs have created an intolerable resource squeeze for all medical providers, whether they are hospitals, academicians or physicians in practice. Increasing regulations and need for documentation of performance have made the situation even more complicated. The ubiquitous ‘razor’s edge’ balancing act between high quality and low cost will only become more difficult as the ‘edge’ becomes more finely drawn. Although new technologies and new drugs improve patient outcomes, they make care more expensive. As insurance companies raise premiums and decrease benefits, it is unclear whether patients will be able to afford care at all.
Even as the armamentarium and capabilities of healthcare providers change, patients are also changing. Increasingly, patients are consumers and are empowered to make decisions about their healthcare. The underlying causes range from the rise of consumer advocacy groups to the redefinition of industry’s relationships with patients. Hundreds of millions of dollars are now spent on direct-toconsumer advertising of drugs and equipment.
There is no doubt that cardiovascular medicine is in the midst of phenomenal change. In the short term, procedures and devices will continue to dominate. In the area of coronary artery disease, drug-eluting stents offer seemingly unlimited promise, while in electrophysiology, implanted cardiac defibrillators and biventricular pacing offer hope for even the endstage patient. Surgical advances such as laparoscopic bypass surgery and the totally implantable artificial heart are now within our grasp. In parallel with these technical developments designed to palliate established disease, there is an increasing emphasis on early detection and prevention. While it may take many years, this proactive emphasis is the surest route to reducing the heavy burden of cardiovascular disease globally. For this reason, as well as for the attendant decrease in costs, it is a critically important path to pursue.
Also holding great promise in reducing cardiovascular disease are the scientific revolutions that are currently under way. The sequencing of the human genome is creating an entirely new approach to medical care – molecular medicine that promises to include the development of infinitely more sophisticated drugs and therapies, applied far more safely than is possible at present. The ability to create tissues from stem cells is giving rise to a new science of regenerative medicine. The possibility that each of us holds the key to treating our own diseases – in our genes and in the form of pluripotent stem cells – is intriguing. With both of these advances, it is somehow appropriate that the future lies within ourselves.
The revolutions of prevention, genomics and regenerative medicine will, if fully realised, burst the confines of conventional conceptions of the healthcare world. How they will affect medical imaging in general, and echocardiography in particular, is impossible to predict. However, as long as echocardiography adds value to the core business of medicine – patient-provider interactions in a search for improved health – there will be a need for its unique contribution.