Author + information
- Siu-Hin Wan, MD∗ ()
- ↵∗Address for correspondence:
Dr. Siu-Hin Wan, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905.
Since the application of ultrasound technology to the field of cardiovascular diseases in the 1950s, echocardiography has evolved from M-mode to 2-dimensional (2D), Doppler, strain, and 3-dimensional (3D) imaging, providing noninvasive and accurate structural and hemodynamic information. Echocardiography is now a fundamental component of general cardiology training and is an integral part of the careers of most early career cardiologists (1). The Core Cardiology Training Symposium 4 (COCATS 4) Task Force states that echocardiography is integral to the practice of cardiology, and all cardiovascular trainees should have competence not only in the clinical interpretation of images, but also with direct hands-on experience (2). The technology-driven younger generation has fundamentally transformed how next-generation physicians learn the cardiovascular anatomy and physiology through echocardiography.
Despite tremendous technological developments in quantitative echocardiography, the underlying man–machine interface has been slow to change. Due to sophisticated machinery, echocardiography has a steep learning curve, compounded by the fact that many operations are not inherently intuitive. And, once habits are entrenched, there tends to be tremendous resistance to change. However, evolution in design by incorporating cues from other industries and investing in the future will have far-reaching, long-term implications. By embracing change, echocardiography could lead diagnostic imaging and drive innovation. There are many potential lessons for trainees regarding ergonomics, efficiency, and precision that are increasingly important in an era of complex technology and of focusing on value in health care delivery.
Benefits of Ergonomic Upgrades
One of the major barriers to widespread adoption of quantitative echocardiography is the amount of time required for accurate measurements, tracings, and calculations. Vendors have invested in improvements on image quality, hardware, software, and processing technology, but the operation of echocardiography machines has remained relatively unchanged. Experienced sonographers and echocardiographers prefer to stay with a particular brand because of operational comfort. Learning to operate different echocardiography machines requires time and effort. Despite the display of essential clinical information, the operator must adapt to varying layouts and interfaces of different machines. In an era where efficiency is paramount, workflow should become a priority in echocardiography development.
According to the Modern Healthcare/Emergency Care Research Institute Technology Price Index, modern cardiac ultrasound systems cost >$160,000 (3). Hospitals and clinics would therefore benefit greatly if workflow can be improved. Patients would have shorter wait times and increased satisfaction, community hospitals would have greater utilization of their machines with their investment, and cardiologists and sonographers could perform a larger number of studies in a given time period (4). Additionally, with improvements in design and ergonomics, sonographers would be less likely to have musculoskeletal workplace injury and have greater workplace productivity (5).
An efficient echocardiographic laboratory must perform both image acquisition and post-processing, including quantitation, calculations, data integration, organization, and structured reporting. New image acquisition techniques or protocols may require an initial investment in time and energy, but studies have demonstrated long-term reduction in scanning time (6,7). Digital technology for post-processing and structured reporting has been shown to increase efficiency as well as patient satisfaction, and thus is an important investment for both academic as well as community practices (8–10). As the role of echocardiography continues to expand, greater efficiency in echocardiography allows for both improved population outcomes as well as long-term cost savings (11–13). Changes to echocardiographic workflow will have a great effect on cardiovascular trainees as well as on early career physicians who seek a career in imaging.
Areas for Improvement
Just as echocardiography initially borrowed technology from other disciplines, other industries and consumer fields may offer clues to optimize efficiency. Many aspects of echocardiography machine operation and design lag far behind those found in cutting-edge consumer electronics and high-tech industries, where user experience drives development and competition (14).
A set of simplified controls is essential. A typical modern echocardiography machine will have multiple knobs and buttons, along with a keyboard, ≥1 touchscreen, a main display screen, and a trackball. More recently, knobs, buttons, and switches have become mostly consolidated to a small number of tactile buttons and a large touchscreen that can control everything. This allows more time for imaging.
Currently, controls and measurements rely on a trackball. What if, for example, instead of using a trackball to trace the area of the left ventricle, one could use a stylus, similar to professionals in the photography and illustration industry? Although they are undoubtedly versatile, the trackball and touchpad are not particularly intuitive or ergonomic, and in many industries, have been largely replaced. Of particular note is the difficulty to accurately trace with a trackball, as small variations in tracing can lead to large deviations in measurements and subsequent calculations. Here, we could turn to the animation, illustration, and photography industries, where the use of a mouse, keyboard, and trackball has been replaced by a touchscreen tablet with pressure-sensitive stylus. Coupled with an ultra-high definition screen, image quality will be enhanced, and measurements and calculations will become more accurate and reproducible. Prior research comparing computer input devices have demonstrated that the stylus allows for less error when pointing compared to a mouse or a trackball (15). One of the major limitations of echocardiography is interphysician and intraphysician and sonographer variability, and improvements in controls will likely minimize this variation and improve precision. Whether it is measurements of wall thickness, biplane volumetrics, or time velocity integral tracing, a pen stylus on a touchscreen would be faster and more accurate than a trackball.
The workflow from image acquisition to report generation can be streamlined. Currently, images are organized by imaging windows and are ordered depending on the preferences of each sonographer. Differences in communication between an echocardiography machine and the underlying reporting software result in significant delays in the final cardiologist’s interpretation. By organizing images in a standardized manner, efficiency could be greatly improved. For example, Doppler interrogation of aortic stenosis requires acquisition from multiple windows (16). By grouping apical, right supraclavicular, and suprasternal notch interrogation of the aortic valve, interpretation can be enhanced compared with organization by the order in which images were obtained.
Furthermore, the incorporation of sensors and software common in consumer electronics can greatly enhance the console interface. The use of a pen stylus, wireless ultrasound probe, and touchscreen tablet could greatly improve the portability of echocardiography. Augmented reality also could provide vital data that can enhance human efficiency and performance. The advent of augmented reality can superimpose vital information on a visual display. In echocardiography, this may translate to 2D and 3D image reconstructions on virtual displays, helping to identify and define optimal imaging windows and enhance settings, including depth and gain. The use of voice recognition can dictate vital information and sort images and measurements. Just as the most successful consumer electronics are easy to use due to close-knit hardware and software integration, medical equipment should become intuitive and simple to operate. Indeed, different interfaces and input devices are currently used for many echocardiography research projects, such as in strain and 3D imaging, where offline measurements and calculations are made for images that have already been acquired.
The next generations of learners are fundamentally different due to the prevalence and integration of digital technology in our daily lives. Students of the millennial generation and beyond are more likely to learn more interactively, with greater use of audio/visual materials, computers, mobile communication, and social media (17,18). The future of echocardiography should be prepared for a future generation of cardiovascular trainees that will be adept at utilizing technology in understanding cardiovascular anatomy and physiology.
These ideas are not without their challenges. For example, the use of a stylus becomes complicated for right-handed sonographers whose hand is already occupied with a probe, and may necessitate deferring measurements until the end of the study. Reorganizing knobs and buttons while changing the interface will disorient those that are comfortable with current controls. Although an ergonomic revolution necessitates discomfort, the rewards are potentially vast, allowing greater accessibility and adoption of echocardiography by both cardiologists and noncardiologists, as well as greatly improving efficiency and workflow in the long term.
Significant changes will require significant investments from vendors. While many of the technologies behind good design and ergonomics already exist in different industries, incorporation into a single platform will require collaboration across disciplines. The fluctuating health care economy can be both an opportunity and an obstacle to a reimagining of the sonographer/ultrasound interface.
Echocardiography decades from now may be very different from the current technology, and this will have profound implications for those training in cardiovascular diseases as well as early career physicians. In an era of increasing quantitation and multiple evolving and maturing techniques, such as strain imaging and 3D echocardiography, attention to operation and ergonomics is just as important as advancement in image quality and upgrades in hardware and software. Although the “Holy Grail” of full automation and machine learning is still distant, for now we should focus on efficiency and precision by turning to seemingly unrelated disciplines to learn and adapt existing designs and modalities. Precision, efficiency, and ergonomics will not only advance the field of echocardiography, but will also allow the next generation of cardiologists-in-training, already immersed in digital technology, to better understand cardiovascular anatomy and physiology through echocardiography.
The author thanks Rekha Mankad, Garvan Kane, Kyle Klarich, Mary Ann Capps, and Daniel Prince from the Mayo Clinic echocardiography laboratory for their dedication to education, advancement of science, and patient care, as well as his mentor, Horng Chen.
Dr. Wan has reported that he has no relationships relevant to the contents of this paper to disclose.
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