Imaging With Ease
By Beth W. Orenstein
Radiology Today
Vol. 25 No. 1 P. 18

Automation and new acquisition techniques address the rising demand for ultrasound.

Ultrasound use in health care for diagnostic imaging and treatment continues to rise year over year. A study published in September 2019 in the Journal of the American Medical Association found that between 2012 and 2016, the use of CT, MRI, and ultrasound grew at an annual rate of 1% to 5%.

There are many reasons for the continued growth in ultrasound utilization. It’s economical, noninvasive, portable, “and the barrier to acquire a system is a lot lower than other imaging modalities, such as MRI or CT,” says Jeff Cohen, general manager of ultrasound at Philips.

While ultrasound use is growing, one of the biggest challenges has always been that ultrasound is highly operator dependent. “You need a highly experienced sonographer in the United States or a physician, globally, where ultrasound imaging is done mostly by physicians,” Cohen says. Another challenge is that patients are increasingly overweight, and a high body mass index makes ultrasound more difficult to perform, especially abdominal ultrasound.

Also, ultrasound scanning can put a strain on sonographers who often must reach across patients and perform repetitive tasks with each exam. According to the Society of Diagnostic Medical Sonographers, up to 90% of sonographers suffer from painful injuries affecting muscles, nerves, ligaments, and tendons from day-to-day job duties. “This can result in difficulty performing work and other activities and cost employers billions each year in direct and indirect costs,” says Roland Rott, president and CEO of ultrasound at GE HealthCare.

On top of these issues with ultrasound is the fact that “many in imaging are being asked to do more exams with less time and resources,” says Anthony Tardi, global head of product marketing for radiology at Siemens Healthineers Ultrasound.

Thanks to the increased demand and staffing shortages, the burden of work in health care is higher on everyone, including sonographers, and can potentially lead to burnout, Rott agrees. According to GE HealthCare’s Reimagining Better Health study published in 2023, the World Health Organization estimates a 10-million-person shortfall of global health care workers by 2030, and 42% of clinicians are actively considering leaving the health care industry.

With demand on the rise and staffing a potentially growing problem, manufacturers of ultrasound equipment have additional impetus to address these issues, and they believe that some of their newest products are making significant improvements in the field. “What we are trying to do is reduce the burden on the user to get the highest confidence [in the] diagnostic image that [is achievable],” Cohen says.

At GE HealthCare, “We are focused on bringing technology to health care providers that helps improve efficiency and productivity while improving diagnostic confidence,” Rott says.

Fortunately, says Matthew Ernst, ultrasound product marketing manager for FUJIFILM Healthcare Americas Corp, “Today’s ultrasound systems are easing the barriers to imaging a wide array of challenging patients’ conditions through automated processes and new image acquisition techniques. This is crucial as it helps sonographers receive clinical answers quickly and easily. Empowering sonographers to easily scan their patients helps prevent burnout, contributes to better [return on investment] for health care facilities and, importantly, helps elevate a more accurate diagnosis for the patient, if there is any.”

Ergonomic Concerns
To help prevent ergonomic issues, manufacturers are incorporating a more user-friendly interface and touchscreen technology in their ultrasound systems. GE HealthCare’s LOGIQ E10 enables operators to customize their probe presets and workflow, resulting in fewer manual adjustments, keystrokes, and button presses. Fewer manual adjustments mean less strain not only on sonographers’ hands and wrists but also on their entire musculoskeletal system.

The growing trend of obesity in patients—according to the World Health Organization, the number of patients considered obese has tripled since 1975— makes ergonomic scanning more difficult because it requires sonographers to use greater pressure. When sonographers need to use excessive pressure to obtain quality diagnostic images, it can strain their upper extremities. Siemens Healthineers’ Ultrasound developed its DAX— Deep Abdominal Transducer—to address this concern. A study performed by Sound Ergonomics says the transducer requires about 70% less force compared with a conventional abdominal transducer when scanning the abdomen of a larger patient. Introduced in 2019, the DAX was developed for Siemens Healthineers’ ACUSON Sequoia ultrasound system.

FUJIFILM has also developed probes that focus on deep abdominal imaging, such as its adult convex probe, which uses single-crystal elements to transfer acoustic energy more efficiently into the body and obtain clinically relevant information from deep structures in patients with a high body mass index, Ernst says.

Philips, too, has worked on reducing the weight of its transducers, Cohen says. They are easier for sonographers to use and put less strain on them when scanning. “Years ago,” Cohen says, “transducers were really, really heavy, as were the cables, and neither were easy to maneuver.” The newest designs are much lighter and easier to move across and around patients.

Philips also has studied sonographers’ hands to make sure the form factors of the transducers meet their individual needs. “We have a really good design group that looks at people’s hands all over the world, as a person who scans in Japan may have different needs from a sonographer in the US or in Brazil,” Cohen says. “Then, we make sure that the handle meets their needs because if the handle and the grip aren’t correct, it puts a lot of strain on the sonographer’s body.”

Likewise, Rott says, GE HealthCare’s latest ultrasound systems include wrist rests to help relieve fatigue, adjustable monitors and keyboards to accommodate various viewing and typing angles, and probes that are comfortable to hold and maneuver.

Increasing Automation
Manufacturers are addressing sonography workload issues by addressing workflow. Designing ultrasound equipment that helps with workflow and reduces scan time is an area of emphasis. Philips has introduced Auto SCAN Assistant, which makes it possible for sonographers to optimize images without having to press any buttons. “With this tool, we found that we can reduce the number of image manipulation steps by almost 50%,” Cohen says. The reduced strokes not only have ergonomic benefits but also reduce the time needed to acquire images.

Fujifilm’s ARIETTA line of ultrasound systems comes equipped with intelligent automatic functions designed for a streamlined workflow, Ernst says. “Ultrasound systems that help streamline the workflow of sonographers can help address the shortage of health care professionals by being able to scan more patients and reduce burnout.”

Siemens Healthineers Ultrasound is also “focused on automation so that when the sonographer puts the transducer down, there’s automation happening dynamically to optimize the focal zones and make it easier and faster to acquire images,” Tardi says.

Automation is also easier on patients, Tardi says. For example, in the past, ultrasound elastography for liver disease would require patients to hold their breath five to 10 times while individual acquisitions were made. “What we’ve done is automate a full elastography of the liver, which makes the liver elastography acquisition time up to 75% faster,” Tardi says.

Another example is Siemens Healthineers’ shear wave elastography for assessing breast masses. With this ultrasound technology, “practitioners are able to characterize breast masses as malignant or benign by measuring lesion stiffness,” Tardi says. A study published in 2023 in Investigative Radiology found that shear wave elastography reduced the number of false positives in evaluating breast masses, reducing the need for biopsies. Shear wave elastography for breast imaging has been around for a long time, but it has been shown to generate a significant number of false negatives, Tardi says. “Last year, we released our next-generation 2D-Shear Wave Elastography and improved the sensitivity of the shear wave elastography technique to eliminate this diagnostic challenge.”

AI’s Impact
AI is driving health care overall, and ultrasound is included in this trend, Rott says. New AI-driven tools are available with systems such as GE’s Venue Family with Caption Guidance, which is used to acquire diagnostic-quality cardiac ultrasound images. Venue is designed for point-of-care imaging and features automated and advanced clinical tools that enable fast assessments, support clinical decision-making, and help monitor patient progress. The Venue Family also includes handheld ultrasound, the Vscan Air SL, a pocket-sized portable ultrasound that can help clinicians efficiently collect and view cardiac and vascular images at the point of care.

Siemens Healthineers recently unveiled its ACUSON Origin, a cardiovascular ultrasound system with AI capabilities that help it identify the anatomy being imaged and anticipate the next steps needed for patient care. Tardi says a routine echocardiogram requires around 45 to 50 measurements. With this system, the sonographer or echocardiographer does not need to spend time searching for tools in submenus. A single AI button can perform hundreds of measurements by looking at the current image on the screen, reducing the echo exam time. Tardi says it not only reduces scan time but also improves ergonomics for the technologist who performs the exam.

Philips is piloting AI in its Lumify Handheld Ultrasound to simplify key measurements needed to identify abnormalities during pregnancy. Another advantage of AI is that it can reduce training time from weeks to hours, Cohen says. In areas of the world where women are underserved, the deployment of an AI-assisted tool could be life changing, he adds. Ultrasound is the first tool of choice to scan pregnant women, but it also requires training to understand how to scan properly and correctly to make the correct image interpretations. Lumify allows nonexpert users to scan pregnant women and obtain a comprehensive set of obstetric measurements that can be lifesaving. It allows frontline health care workers such as midwives to identify potential problems in pregnancy at an early stage and potentially significantly reduce the number of women who die because of pregnancy. Philips is working with the Bill & Melinda Gates Foundation to bring this technology to underserved and rural communities in developed and developing countries worldwide.

In 2022, FUJIFILM Healthcare Americas Corp released its DeepInsight technology, which uses cognitive technology to distinguish between echo signals and electrical noise in ultrasound scans, to selectively extract the signals necessary for deep tissue visualization. “This results in high-quality images, even from deep and challenging regions of interest,” Ernst says.

In addition to the growing use of AI and cognitive technology in ultrasound, “We are seeing that today’s systems are using novel transmission and reception technologies to achieve clarity of imaging from near to far field,” Ernst says. “FUJIFILM’s wide range of probes leverage enhancements in transducer element material and design to help sonographers achieve excellent images.”

In addition to the noise reduction achieved by DeepInsight, the ARIETTA 750DI offers an advanced version of its eFocusing feature. eFocusing is an image acquisition technique that eliminates the need for focal zones by dynamically focusing at all depths. Ernst says eFocusing PLUS augments the improvements in far-field visibility by adding frequency compounding to the equation for improved penetration.

Staffing Support
Another way in which manufacturers are addressing staffing shortages is with teleultrasound. Cohen says Philips Collaboration Live lets users quickly and securely talk, text, screen share, and video stream directly from their ultrasound system to a PC or mobile device. “This allows them to extend their teams without expanding them,” Cohen says.

Care team members have access to on-demand experts for real-time remote clinical diagnosis with system control, decision support on complex exams, and training on care protocols. “Imagine you’re in a rural clinic, and a challenging case comes in that would benefit from more expertise,” Cohen says. “With Collaboration Live, you can remotely dial up a clinician at an academic center, and, in real-time, they can consult with you. The expert can actually take over control of some of the system to get to that diagnosis and provide the help you need.”

Collaboration Live is also useful in areas of the country that may have fewer resources with specialized knowledge, such as, for example, a single breast imager. “We’re finding a lot of utility in areas of the country where expertise is limited, and that expert is trying to share his or her time between many different locations,” Cohen says.

Portable ultrasound machines are also helping with staff shortages and workflow issues. Philips’ next generation Ultrasound Compact 5000 Series, a cart-based portable compact unit, is an example. It’s designed to fit the needs of many specialties, including general imaging, cardiology, obstetrics and gynecology, and point of care. Clinicians are under increased pressure for higher patient throughput and are being asked to perform more inpatient ultrasound exams outside of the echo or imaging lab, Cohen says. A portable system allows clinicians to provide care regardless of where the patient is located, he adds.

GE HealthCare’s portfolio also includes handheld ultrasound solutions to help accelerate diagnoses and treatment decisions. The Vscan Air family includes two flexible, wireless, dual-probe handheld ultrasound options at the point of care: the new Vscan Air SL, which includes a sector-phased array transducer for rapid cardiac assessments, and the Vscan Air CL, which includes a curved array transducer for abdominal imaging and obstetric assessments, among other exams.

Ultrasound’s Future
In the future, Ernst believes ultrasound will replace biopsies in some instances. One example is liver disease, which is on the rise. Fujifilm’s ARIETTA 650 and 750 DeepInsight systems are noninvasive tools that can measure fat attenuation and elasticity to assess liver health in real time, reducing the need for patients to undergo painful biopsies, Ernst says.

“These systems are engineered to support health care providers to quickly, confidently, and painlessly assess liver health and determine the extent of fibrosis or steatosis present in a patient’s liver,” he says. “Additionally, our next generation ultrasound systems combine shear wave elastography with an intelligent attenuation measurement (9iATT), providing quantitative evaluation of both fibrosis and steatosis in a single measurement.”

Rott sees ultrasound expanding in more areas in the future, including in surgical visualization. “Surgical visualization is a fast-growing area in which surgeons can use ultrasound to see exactly where they are operating in real time vs relying on static images from a CT scan,” he says. With the acquisition of BK Medical in 2021, GE HealthCare has complemented its ultrasound product portfolio with real-time visualization and guidance technology in surgical disciplines such as neurosurgical, urological, colorectal, and robotic-assisted procedures, Rott says, adding that “The future of ultrasound technology is exciting.”

— Beth W. Orenstein of Northampton, Pennsylvania, is a regular contributor to Radiology Today.