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Roadmap to success: Blueprint for enterprise-wide deployment of a point-of-care ultrasound platform, inclusive of governance, policy, education, credentialing, and quality assurance (Part 2)
*Corresponding author: David Waldman, Department of Imaging Sciences, University of Rochester, Rochester, New York, United States. david_waldman@urmc.rochester.edu
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Received: ,
Accepted: ,
How to cite this article: Waldman D, Doughton J, Pino C. Roadmap to success: Blueprint for enterprise-wide deployment of a point-of-care ultrasound platform, inclusive of governance, policy, education, credentialing, and quality assurance (Part 2). J Clin Imaging Sci. 2025;15:28. doi: 10.25259/JCIS_76_2025
Abstract
Point-of-care ultrasound (POCUS) has emerged as a cost-effective diagnostic tool that significantly enhances physical examinations. Serving as an extension of traditional examination methods, POCUS is particularly appealing to the next generation of clinicians. It holds the potential to become the modern-day stethoscope in various medical assessments and procedures. At the University of Rochester, we are in the midst of a major initiative, deploying 2,000 POCUS probes while simultaneously reinforcing compliance standards for image storage and documentation across established POCUS platforms. Three years into our 4-year deployment plan, we will discuss the evolution of our governance structure, improved utilization, continued educational initiatives, and credentialing strategies. Over the past decade, POCUS adoption has grown organically, and our goal is to implement a comprehensive strategy that ensures adherence to established protocols for image storage and documentation. At present, we have successfully deployed 1,199 probes, up from 789 in year 2, with integration across more than 70 departments and divisions within our information technology (IT) platform. Notably, this implementation has led to a 26% growth in hospital charges, highlighting the tangible impact of POCUS integration. However, achieving compliance and education among established providers continues to be a challenge. The integration of fellowship-trained POCUS physicians into various departments has been invaluable, and developing physician champions has significantly improved both utilization and compliance. Recent initiatives include transitioning from traditional bladder scanners to ultrasound (US) probes mounted on iPad stands and developing a nursing POCUS-guided US program. Nursing education has played a pivotal role in supporting this transition. Over the first 6 months, 86 US probes used by nursing staff have facilitated approximately 70,000 bladder examinations.
Keywords
Enterprise imaging
Point-of-care ultrasound
Ultrasound IT platform
INTRODUCTION
Ultrasound (US), known for its cost-effectiveness and portability, has emerged as a promising imaging modality to enhance and expedite the diagnosis of various diseases, ultimately improving clinical outcomes. Lung point-of-care US (POCUS), for example, has gained widespread recognition through multiple studies demonstrating its superior sensitivity and specificity in detecting pneumonia compared to the traditional “gold standard” of chest X-ray.[1-4] This advantage extends to the detection of gallbladder disease, ascites, effusions, and renal stones.[5-9] At our institution, we strongly believe that this is a “positive” disruptive technology not only to reduce overhead costs but also to improve the efficiency of medical care.[10] Key initiatives in year three have focused on developing new models to assess return on investment (ROI) and the overall value of POCUS to patient care. We continue to implement programs to follow our heart failure patients in a longitudinal manner across all sites of care. Continued education, acceptance, and integration of POCUS into existing workflows have been our largest challenges. We are in the process of converting our post-thoracic procedure evaluations from chest X-ray to POCUS.
MATERIALS AND METHODS
In January 2022, the University of Rochester Medical System launched a comprehensive, enterprise-wide deployment of a new POCUS platform. Over 4 years, more than 2,000 handheld US probes will be distributed across both inpatient and outpatient settings, available to students, nurses, and healthcare providers alike. Simultaneously, existing POCUS machines are being integrated into the same IT platform to improve institutional compliance with image retention and documentation protocols.
The Butterfly Network (Butterfly Network Inc., Burlington, MA) was selected as our primary probe and IT vendor. Butterfly was chosen for their innovative probe design and seamless integration into existing IT systems. The probe features a tunable digital chip composed of 9,000 programmable microsensors, which allows a single probe to serve a variety of uses. This contrasts with many POCUS vendors who rely on piezoelectric crystal-based probes which require multiple probes to cover a range of use cases. In 2023, Butterfly introduced the IQ3 probe which boasts improved resolution and usability. We continue to collaborate with the vendor to refine workflows and enhance utilization. We have converted a portion of our IQ+ probes to IQ3 depending on the provider’s specific needs.
Governance
The institution developed a comprehensive governance strategy with the clinical council serving as the overarching body. The council includes representation from physicians, advanced practice providers, nurses, pharmacy, quality assurance (QA), and legal counsel. This group was responsible for establishing the institution’s guidelines for POCUS use.
Over the initial months, a new institutional point-of-care policy was developed. This policy outlined clear responsibilities for individual departments while ensuring centralized oversight by the program. Key elements of the policy include credentialing, QA, infection control, communication protocols, documentation standards, and image retention policies. While some departments had existing policies, streamlining the process across the entire enterprise promoted a more unified and consistent program.
However, as of today, we have been unable to fully implement this policy. For full implementation, all of our cart-based US machines must be integrated into the POCUS workflow. This initiative has taken longer than anticipated. The policy mandates that all POCUS images should be stored in our enterprise picture archive communication system (PACS) and we expect this work to be completed by late spring.
Education
Establishing a structured program with designated leadership was crucial to drive the process, ensure quality review, mentor participants, maintain compliance, and foster ongoing education. The director and assistant director of the institution’s POCUS program is responsible for managing the day-to-day operations to ensure the program’s success. Leadership also oversees equipment maintenance, ensures the economic viability of the program, and provides development and mentorship opportunities for less experienced clinical sonographers within the organization.
Departmental champions have played a critical role in developing educational programs, setting standards, and maintaining QA. Over the last year, fellowship-trained POCUS leaders/champions have been hired in the departments of Critical Care, Pulmonary, Family Medicine, Pediatric intensive care unit (PICU), and Neonatal intensive care unit (NICU). These leaders have been instrumental in driving QA initiatives within their respective departments. The long-term success of having champions can be seen in departments such as our Emergency Medicine, where they have had a well-established department for years.
Technology and development
To optimize workflow efficiency and probe utilization, a collaborative workgroup of providers and nurses was formed. This group partners with vendors to tailor hardware requirements, improving the delivery of patient care. A key lesson learned has been the importance of seamlessly integrating innovative technology into existing workflows. Departments previously using POCUS were slow to adopt new workflows. After extensive discussion with Butterfly, we jointly developed an alternate encounter-based workflow where users could continue to document in the electronic medical record (EMR) (Epic Systems Corporation, Verona, Wisconsin) without having to access or enter information in the Butterfly cloud. This has greatly improved POCUS compliance.
Quality
Quality initiatives are focused on individual departments. Initially, quality programs are centrally coordinated to educate departments on credentialing and ongoing QA efforts. Task forces are established to define appropriate use cases and mechanisms for monitoring quality. Quality is assessed based on two primary factors: Image quality (whether the study is of sufficient quality to answer a specific clinical question) and whether the provider accurately interpreted their findings based on the images provided. Feedback is provided to providers in both a numerical score and a written assessment. Over time, larger departments have become proficient in performing their own QA while smaller departments collaborate with larger departments.
Nursing
Two primary nursing initiatives have been launched focusing on POCUS applications for bladder scanning and US-guided IV placement. Nurses are a driving force within the enterprise, and they require access to top-tier technology to deliver the highest level of patient care. Developing new policies and educational platforms was necessary for the success of these initiatives. It took over 12 months to finalize a new bladder scanning policy, and POCUS IV teams are currently undergoing training. In addition, ergonomic improvements are being made to optimize IV cart development. Nursing has taken over ownership of the education for US-guided IV placement. This is primarily driven by the peripherally inserted central catheter (PICC) and vascular access teams.
Billing
Close collaboration with individual departments has been essential to understanding their unique billing workflows. Where possible, automation of billing processes has been implemented. Given the variability in billing practices across departments, individualized testing is required for each department’s billing system. The departments choosing to use a direct EPIC documentation workflow utilize their current billing process of charge capture.
Workflow
This year has brought a significant change in workflow. Departments that were already proficient in POCUS were initially reluctant to adopt a new system for POCUS reporting and storage. An alternative workflow for providers wishing to report directly in our EMR or performing US-guided procedures was developed in collaboration with our vendor. These reports are automatically finalized, triggering images to go directly to PACS, and then are billed through Charge Capture. While this workflow limits the ability to perform QA and track usage through the Butterfly Cloud, it represents a significant trade-off for efficiency and improved utilization. Workflow patterns are developed department by department. It has been interesting to watch each department decide on a specific workflow [Flowchart 1].
- The upper workflow is for providers using the Butterfly cloud for documentation, with automatic billing integration. This setup offers the advantage of easier quality assurance and resident documentation. Below, the auto-finalize workflow places documentation directly into EPIC, with charge capture used for billing. Providers performing procedures or previously conducting point-of-care ultrasound examinations will find this workflow more efficient. In both workflows, completed images are stored in the institutional picture archive communication system and documentation in the electronic medical record.
RESULTS
Medical School
The medical school curriculum continues to evolve to integrate POCUS into the majority of problem-based learning courses. As of the most recent update, we have accumulated 4,559 studies in our medical student educational folder, marking a 28% increase year-over-year. Of these studies, 3,153 have accompanying documentation, a 5% increase compared to the previous year. In addition, 70% of these studies underwent QA by their preceptors with follow-up.
Clinical enterprise
The deployment of 1,199 probes across 75 active departments resulted in the creation of 22,890 studies, a 141% increase from the previous year. Of these, 18,385 studies were forwarded to PACS and EPIC. Among these studies, 63% underwent QA. While this percentage has decreased, it reflects the overall increase in POCUS procedures year-over-year. These procedures undergo QA separately at the department level and not with the diagnostic examinations. Hospital charges have continued to rise with a 26% increase [Flowchart 2 and Pie chart 1].
- 2024 Point-of-care ultrasound device fleet. There are 888 active users.
- Illustrates the 2024 device fleet and its distribution. The majority of studies continue to be conducted using non-butterfly devices. BFLY: Butterfly, NBD: Non-butterfly device.
Bladder scanning
During the initial 6 months, 86 nursing US probes were deployed across the enterprise, resulting in over 70,000 scanning sessions during that period.
Operational
A plan has been developed to address operational needs through the IT help desk, focusing on departmental onboarding and probe/device concerns. This process was successfully implemented last year. Despite this, some departments continue to struggle with utilization. Barriers include challenges related to education, concerns over litigation, and as previously mentioned, the policy is not yet enforced since all cart-based systems are not connected to the cloud.
DISCUSSION
Initially, a collaborative tool was developed with Butterfly to assess the maturity of our POCUS program. As an institution, we conducted evaluations both before and after the program’s launch covering several domains: Education, credentialing, EMR integration, governance, leadership, billing, and adoption rates. Table 1 illustrates the program’s progress pre- and post-initiation, highlighting significant early maturation. There continues to be a natural maturity progression.
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As anticipated, challenges arose in credentialing, departmental leadership, clinical outcomes, billing, and adoption rates. Since many POCUS programs evolve organically, credentialing challenges were expected.
In the post-COVID era, healthcare providers are exceptionally busy, and improving adoption rates requires seamless integration into clinical workflows with clear evidence of clinical outcomes. Without tangible results, providers may view POCUS as an additional burden. Establishing robust, research-driven clinical outcomes will take time. However, in February 2025, we launched abdominal aneurysm screening programs within our family medicine and primary care network. While these programs will require years to fully demonstrate their clinical benefits, a borderline aortic aneurysm was identified in the first 10 patients scanned [Figure 1]. Letters have already been sent to eligible patients within our primary care network, and the patient feedback has been overwhelmingly positive. Patients reported that they were more likely to complete this screening if it was offered in their primary care clinic. This program also provides an additional platform for controlled provider education and offers an opportunity to help primary care physicians become more comfortable with both scanning and interpreting images, which is crucial for long-term adoption.
- One of the first ten patients seen in the family medicine clinic for abdominal aortic aneurysm screening demonstrated aortic dilatation (arrow).
Over the past year, there have been many advances in artificial intelligence (AI) in the POCUS arena. AI is increasingly enhancing POCUS by improving diagnostic accuracy, automating image interpretation, and facilitating medical education. AI algorithms can now identify specific US artifacts, such as B-lines in lung imaging, aiding clinicians in real-time differential diagnosis and patient monitoring.[11]
In low-resource settings, AI-powered POCUS has demonstrated high accuracy in detecting conditions like pneumonia, offering a cost-effective alternative to traditional imaging modalities.[12] In addition, AI integration in POCUS devices provides immediate feedback during image acquisition, guiding users to optimize image quality and reducing the need for extensive training. There are algorithms for AI-driven diagnosis of deep venous thrombosis[13] and pneumothorax[14] currently being evaluated for the Food and Drug Administration approval. AI has been used to help train providers performing studies[15] along with the increase in the use of teleguidance.[16] These advancements position AI-driven POCUS as a valuable tool in enhancing patient care across diverse clinical environments.
A longitudinal initiative aimed to reduce readmissions by tracking fluid status in cardiac patients faced difficulties in getting off the ground due to high turnover rates across parts of our medical center. Fortunately, the institution has hired a new champion who is expected to help move this project forward. Ensuring that medical students and residents are adept with the technology is also crucial for accelerating faculty engagement. There have been recent studies[1,17,18] highlighting the advantages of POCUS in the critical care setting.
Continued concerns among providers regarding legal implications and the shift from diagnostic imaging to an extension of the physical examination – particularly in primary care – highlight the need for strong education and clinical champions. One of the most recent articles highlights that one of the most common reasons for legal difficulty is not performing the POCUS examination.[19] Billing practices have also raised concerns, prompting suggestions for an enhanced billing model that includes POCUS as part of the physical examination charges. While we have seen a continued increase in hospital charges (26% in 2024), changes in healthcare practices have been predictably slow. To address these concerns, we have highlighted several clinical wins, such as the early detection of bladder tumors, cholecystitis, pneumonia, pleural effusions, endocarditis, and fluid overload, which are documented on our institution’s intranet. Our primary care physicians have opened an aortic aneurysm screening clinic for their own eligible patients.
Below is an overview of progress and challenges across multiple domains
Education
As medical students rotate through various clinics, preceptors have become much more engaged in US education. However, there have been challenges in having students bringing their US probes to the clinic. This has been multifactorial. Educational approaches have evolved, shifting toward provider-driven education, intensive care unit (ICU) and hospitalist teaching rounds, and virtual office hours. We have seen increased requests for US probes and education driven by young providers encouraging seasoned clinicians to engage with the technology.
Incorporating POCUS training into the school of nursing APP program has also received positive feedback and strong engagement. Medical students continue to push faculty to new levels of proficiency; for example, an orthopedic instructor had a student perform a shoulder US in their clinic before a provider appointment, which was later compared to a previously obtained MRI, resulting in impressive correlations. Anticipated changes in practice patterns are expected over the next few years with providers continuing to request continuing education credits. The Department of Orthopedics has also incorporated cadaver scanning into resident education alongside procedural training.
A new teleguidance program has achieved high praise. This allows proficient providers in the US to precept and remotely take control of a provider’s probe as they scan. This program has allowed the providers to gain confidence and become more comfortable with scanning techniques.
Credentialing
While some providers believe that they are already credentialed to provide POCUS services, deficiencies in the process have been eye-opening for both providers and departments. Streamlining the credentialing process has been a priority, and QA programs are now being distributed to departments to reduce the central burden. The program has attempted not to make the process too onerous. We try to concentrate on US basics as opposed to learning every possible examination. It is interesting to note that the most frequently reported current procedural terminology (CPT) code is 76882, which is a non-vascular extremity code. Non-vascular extremity scanning has not been covered in our initial education. Providers have developed insight as to where the technology can improve patient care.
EMR integration
IT integration has been relatively straightforward, but operational workflow for providers has posed challenges, particularly for those accustomed to traditional US machines. Acceptance has been smoother among providers new to POCUS. Providers can now view clinical POCUS images alongside PACS images from imaging, cardiology, vascular surgery, and Obstetrics and Gynecology (OB/GYN). Only providers with credentialing privileges listed in their Delineation of Privileges can send images across the platform to the EMR and PACS. Educational images remain stored solely in the cloud for providers still working toward credentialing. Recently, the auto-finalization workflow was implemented where, upon ending the examination, the images automatically get sent to PACS along with a note to view the EMR for documentation. This made it so the provider could skip the step of having to log into the cloud and work within another application. The departments previously using POCUS mostly chose this workflow. While the emergency department has been using POCUS for over 15 years, they have chosen to use the Butterfly workflow which allows improved POCUS tracking and QA.
Governance
Our governance model continues to evolve with the clinical council serving as the overarching governing body. Subcommittees, such as IT and operations, have been developed out of operational necessity. While ROI has been challenging to assess, utilization numbers have been impressive. However, demonstrating financial viability remains difficult, particularly in the inpatient setting where we are operating within a diagnosis related group (DRG) framework. Isolating revenue from POCUS procedures in such a complex medical ecosystem has proven difficult, and, unfortunately, we have focused on charges rather than more precise revenue tracking. The program initially has been run out of the Information Systems Division. Next year, we will transfer the program to our quality institute where the focus will change to patient quality initiatives and ROI. Newer guidelines have recently been published by the Healthcare Information and Management Systems Society Association of Medical US on POCUS governance.[20]
Leadership
Departmental maturity varies significantly across the institution. The Emergency Department has a mature program, while the ICU, despite incorporating POCUS into clinical practice, lacks the necessary infrastructure. Significant efforts have been devoted to building program infrastructure, including education, credentialing, and QA. The new auto-finalizing workflow should help enhance utilization in departments like the ICU. Some departments, such as nephrology and medicine, have established joint programs to ensure sustainability, like a collaborative QA program. Critical care has now brought on fellowship-trained POCUS providers to enhance utilization, education, and compliance. As previously discussed, other departments (Gastrointestinal/Nephrology/Family Medicine/Critical Care/PICU/NICU) have made similar investments.
Challenges remain in fully integrating POCUS into existing workflows, particularly among seasoned providers. Focusing efforts on students, residents, fellows, and APPs has shown promise in improving adoption. Strategic planning and alignment with institutional EMR systems are critical. Providers’ concerns about legal challenges and increased medical expenses emphasize the importance of appropriate use and demonstrating cost-effectiveness through data. We continue to highlight interesting cases across the enterprise [Figure 2 and Videos 1-4].
- A case of bowel wall thickening (arrow) performed by a GI physician using a Samsung ultrasound machine. Ultrasound has now become the standard tool for physical examination.
Video 1:
Video 1:A patient presenting to the family medicine clinic for abdominal aortic aneurysm screening was found to have a liver abnormality. The patient was referred to radiology for a full diagnostic scan, which revealed an area of focal fatty sparing. Video available online at https://doi.org/10.25259/JCIS_76_2025Video 2:
Video 2:Loculated ascites performed by our hospitalist service. Video available online at https://doi.org/10.25259/JCIS_76_2025Video 3:
Video 3:Liver abscess with a small pleural effusion. Performed by the hospital medicine service. Video available online at https://doi.org/10.25259/JCIS_76_2025Video 4:
Video 4:Cardiac examination performed by a hospitalist, illustrating a positive “D” sign, indicating a dilated right ventricle. Video available online at https://doi.org/10.25259/JCIS_76_2025CONCLUSION
The enterprise-wide deployment of POCUS has been both rewarding and challenging, representing a significant paradigm shift in medical practice. Success depends on sufficient resources and funding as well as centralized operational oversight initially, transitioning to departmental control over time. Education and QA will remain critical throughout this process. Moving forward, we will focus on the last large department “Go-Live” in anesthesia, while also revisiting previously deployed departments and divisions with limited utilization to further understand existing barriers. A new chairman brings hope that looking at POCUS across all phases of care may not only be feasible but crucial in improving overall patient care.
Ethical approval:
The Institutional review board approval is not required.
Declaration of patient consent:
Patient consent was not required as the images/data used are completely anonymized and do not contain any identifiable information. Every effort has been made to ensure patient anonymity. No personal details or identifying features are included in the images or content presented.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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